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HEALTH SERVICE IN 
INDUSTRY 



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THE MACMILLAN COMPANY 

NEW YORK • BOSTON • CHICAGO • DALLAS 
ATLANTA • SAN FRANCISCO 

MACMILLAN & CO., Limited 

LONDON • BOMBAY • CALCUTTA 
MELBOURNE 

THE MACMILLAN CO. OP CANADA. Ltd. 

TORONTO 




A CENTRAL DISPENSARY 

Note Good Light, Unit Tables and Simplicity of 

Arrangement 



HEALTH SERVICE IN 
INDUSTRY 



>»\r 



BY 



W. IRVING CLARK, JR., M.D., F.A.C.S. 

Service Director, Norton Company, Worcester, Mass. 

Lecturer on Health Administration in Industry, Harvard Medical School; 

Assistant Surgeon, Memorial Hospital, Worcester, Mass. 



J?eto gorfe 

THE MACMILLAN COMPANY 
1922 



Printed in the United States 
of America 






Copyright, 1922 
By THE MACMILLAN COMPANY 



Set up and electrotyped. Published April, 1922 



2Jhe iHaksBibt $r?s8 

E. E. DONNELLEY & SONS COMPANY 
CHICAGO 

§>",LAfio9660 
W 19 1922 



TO 

MY WIFE 



PREFACE 

The object of this book is to give to those having 
no actual experience in industrial medicine a short 
workable plan outlining the administration and 
methods of a health department in industry. 

The author has not attempted to discuss more 
than one approved method of doing a thing. He has 
not attempted to give methods of treatment except 
as examples. Everything suggested has been tried 
and is in use in some large factory. 

It is presupposed that the reader is either a doc- 
tor or the superintendent of a factory. Most of the 
text should be clear to either reader. As it is writ- 
ten for both doctor and layman, certain sections 
have been necessarily written with great simplicity. 
The book is based largely upon a course of lectures 
given by the author at Harvard Medical School. 



Vll 



CONTENTS 

CHAPTER PAGE 

I. Industry and Organization 1 

II. The Medical Needs of a Small Factory ... 15 

III. Organization of a Medical Department in a 

Large Factory 25 

IV. Factory Dispensaries 37 

V. The Industrial Physician and the Industrial 

Nurse 54 

VI. The Physical Examination 69 

VII. Accidents and Their Treatment 83 

VIII. Sickness in the Factory 97 

IX. Sanitation Ill 

X. Special Problems 127 

XI. Cost of Medical Supervision 147 

AND 

Economics of Industrial Hygiene 



IX 



HEALTH SERVICE IN INDUSTRY 

CHAPTEE I 

INDUSTKY AND OKGANIZATION 

Industry represents one of the large groups of 
gainful occupations. It numbers millions in its em- 
ploy. There are few parts of the country in which 
it does not exist, none to which its results are not 
vital. 

Its tendency is always toward growth and expan- 
sion, thus gathering to itself an increasingly large 
proportion of the population. The products which 
are the end result of industry are infinite in variety, 
and the methods of production are equally varied. 

Industry is made up of units called factories, very 
much as the body is made up of units called cells and 
just as the body grows and maintains its health 
when the cells are functioning normally, so the coun- 
try as a whole prospers when factories are running 
smoothly with maximum production. 

The country is dependent on industry and indus- 
try is dependent upon itself. This dependence has 
developed an interweaving network of interests 
between factories. 

The object of industry is to convert crude sub- 
stances into articles which can be used and to dis- 
pose of these articles by sale. A factory purchases 

1 



2 HEALTH SERVICE IN INDUSTRY 

crude substances and by a series of machine opera- 
tions produces a finished article. This process of 
conversion of crude substances into finished articles 
is known as production. The articles produced must 
be sold and the business managed and financed. 
From this simple analysis we see that in every fac- 
tory there are three great divisions, administration 
(which includes finance), production and sales. 
Each one of these divisions is complete in itself, but 
each is closely allied to both the others. 

There is, however, a fourth division which is quite 
separate from the other three. This division deals 
with personnel and its problems. It is closely allied 
to the other three divisions, since it has to do with 
the human factor in each, but inasmuch as it deals 
most intimately with production it is sometimes 
classed under this division. It should, however, be 
considered separately, as will be shown later, and 
operate as a separate division. 

The basis of factory organization may be laid 
down somewhat as follows : 

A board of directors which controls the policies 
and development of the company. 

A division of administration which controls the 
actual work and development. 

A division of production which controls all the 
actual manufacturing. 

A division of sales which controls all the selling 
of the completed product. 

A division of service which controls all matters 
to do with the personnel of the organization. 

The above outline is diagrammatic. The organ- 
ization of large factories is extremely complicated, 



INDUSTRY AND ORGANIZATION 3 

of small factories very simple, but if the plan out- 
lined above be held in mind as a basic diagram, the 
complications are more readily understood. In the 
small factory the same idea exists except that two 
or more divisions may be represented in the work 
of a single man. The factory has but one object, 
to produce. If it fails to produce it dies. Produc- 
tion may, therefore, be said to be the life of industry. 
To quote Selby:i 

"Anything which is capable of facilitating pro- 
duction is welcome to industry so long as its cost 
is not excessive. The test is its ability to increase 
the quantity or to reduce the cost of production 
without impairing the quality. "Witness the manu- 
facturer who pays an efficiency engineer $17,000 for 
three months' work in rearranging the machines in 
his factory in order that materials may be moved 
more rapidly from the raw state to the finished 
product, or the manufacturer who discards a whole 
battery of smooth-running, though antiquated, ma- 
chinery in order that he may install improved ma- 
chines capable of greater output. On the contrary, 
anything that retards or does not facilitate produc- 
tion is tolerated by industry only so long as it is 
unavoidable. ' ' 

The ideal of production is a continuous output 
which can be raised or lowered at will to meet the 
demand and which will at all times be of uniform 
quality. If all machines were automatic such an 
ideal could be accomplished but there are many dis- 



4 HEALTH SERVICE IN INDUSTRY 

turbing elements all due to the necessity of employ- 
ing men and women to run the machines. 

As soon as the human element enters, uncertainty 
enters also. When thus considered the personnel 
assumes great importance and it is generally recog- 
nized that the more stable and efficient the personnel 
the closer to ideal is production. 

The Service Division, as stated, has for its func- 
tion the selection and care of the personnel. Like 
any other division it is divided into departments, 
each department being controlled by a foreman or 
manager. The departments may be divided into 
those having to do with the actual care of the em- 
ploye, and those in which the general factors of wel- 
fare predominate. Actual care consists mainly of 
health supervision. According to Mock 2 this division 
may be made as follows : 

1. Health Supervision of Employes. 

(a) Medical Service 

(b) Surgical Service 

(c) Dental Service 

(d) Nursing Service 

(e) Safety Service 

(f) Sanitation Service 

2. Adjuncts to Health Supervision 

(a) Employment Service 

(b) Restaurant Service 

(c) Recreation Service 

(d) Welfare Service 

(e) Insurance Service 

(f ) Banking and Loan Service 

(g) Housing and Community Service 



INDUSTRY AND ORGANIZATION 5 

The interesting point demonstrated is the medical 
aspect of the majority of the services here men- 
tioned. 

The Service Division besides the functions out- 
lined has numerous others which it is unnecessary 
to mention. It may be administered by a service 
director or a service committee, which is usually 
directly responsible to the general manager or a 
vice-president. Because of the distinctly medical 
character of the service department the logical man 
for its head should be a physician. This, unfortu- 
nately, is not often the case. Except in a very few 
factories the service department is controlled by a 
non-medical man. One of the reasons for this is the 
difficulty in finding a physician having the requisite 
administrative training. There is, however, a tend- 
ency toward appointing physicians to this position, 
especially since executive training was given many 
doctors during the war. 

The medical, or health department, is therefore a 
part of the service division according to the plan 
above outlined. It is a complete unit in itself and 
consists of a medical and surgical service with all ap- 
purtenances necessary. It is in close contact with 
the other service departments and must co-operate 
with them in many ways. Thus the visiting nurses ' 
service is often a separate department. This depart- 
ment must, however, work in the closest contact and 
sympathy with the health department to be of the 
greatest service. The employment department is in 
constant contact with the health department through 



INDUSTRY AND ORGANIZATION 7 

the physical examination of applicants and trans- 
fers, and the placing of subnormal workers at work 
for which they are physically fitted. In fact every 
department of the service division is in some way 
correlated with another department of the same 
division and all must co-operate to obtain the re- 
sults desired. Not only must these departments 
work smoothly together, but they must do their 
work in such a way as not to interfere with produc- 
tion. No department can exist which interferes with 
production unless the value to production of its end 
result is greater than the loss caused by the inter- 
ference. Thus the treatment of all injuries at a fac- 
tory dispensary takes a certain number of workers 
from production for a few minutes daily, interfer- 
ing with production. However, the rapidity of heal- 
ing, lack of infection and satisfaction of the worker 
altogether represent a factor of time saved and 
efficiency maintained which more than compensates 
for the interference with production caused by the 
visits to the dispensary. 

The service division may be considered as a num- 
ber of departments, each governed by a department 
head, all co-operating, and each endeavoring to ac- 
complish its desired end with as little interference 
with production as possible. Each one of these de- 
partments has to do in some way with the health, 
welfare or interest of the employe. All are con- 
trolled by a service director or a service committee 
and these last are responsible to the general man- 
ager or vice president of the company. (Fig. 1.) 



8 HEALTH SERVICE IN INDUSTRY 

Since the health or medical department comes in 
close touch with many of the other service depart- 
ments it is necessary briefly to outline the functions 
of the latter. In the majority of large factories they 
consist of the following departments: 

Employment 

Safety Engineering 

Visiting Nurse Service 

Commissary 

Recreation — Games and Athletics 

Housing 

Mutual Benefit Associations 

Banking and Loan Service 

The employment department has for its function 
the hiring, transfer and discharge of all employes. 
Up to ten years ago in the majority of factories all 
employing was done by the foreman or superintend- 
ent. When it was done by the foreman each depart- 
ment hired and discharged on its own account. 
Experience showed that this method while on the 
whole efficient, gave the foreman the power of work- 
ing off personal grudges and hiring men who were 
personal friends. Moreover, the time occupied in 
interviewing and entering the applicant was enough 
to interfere with the foreman's work in production. 
It was then considered advisable to establish a cen- 
tralized employment department where all appli- 
cants were interviewed and then assigned to posi- 
tions in various parts of the factory. 

In order to show what positions are vacant each 
foreman needing a new man, either because one of 
his regular force has been transferred, discharged 



INDUSTRY AND ORGANIZATION 9 

or left of his own accord, daily sends to the Employ- 
ment Department a form known as a requisition. 
This slip states that department number blank is 
in need of two machinists or whatever are the 
man power needs. These requisitions await the 
employment manager each morning and it is his 
duty and that of his department to fill each requi- 
sition from the men applying for positions at the 
factory employment department. Not only must he 
find a man to meet the requirements but he must 
select the man who in every way is best fitted for 
the particular work designated on the requisition 
slip. Now, it is evident, that men may fail in a 
certain position for one of two reasons, first, the 
training and past experience may have been insuf- 
ficient or second, the applicant may not be in proper 
physical condition to do the work. While the em- 
ployment department is competent to judge the 
former, the latter can be determined only by a doc- 
tor's examination and it is here that the employ- 
ment and health departments come into close con- 
tact. The problems which arise by this contact and 
the method by which these are handled will be dis- 
cussed at length later. The employment department 
also keeps a record of absenteeism. Absenteeism is 
one of the factors which plays an important role in 
production. It is determined by daily reports from 
all parts of the factory to the employment depart- 
ment, and the tracing of those absent for three days 
by a special agent of the department. The agent 
may be a visiting nurse or may be a man specially 



10 HEALTH SERVICE IN INDUSTRY 

trained in this work, but without medical knowledge. 
In the latter case, when a worker is found to be 
sick, he is reported to the visiting nurse service 
which takes the case in hand. 

The safety engineering department has for its 
work the protection of the worker from accident. 
This is carried on in two ways, first, by the guard- 
ing of machines and appliances, second, by personal 
instruction of the men and foremen carried on by 
lectures, conferences and printed matter. The 
safety engineering department, because of its inter- 
est in accident prevention, investigates each acci- 
dent which occurs and endeavors to institute means 
by which such an accident may be prevented. 

The health department, therefore, sends a report 
of all serious accidents to the safety engineering 
department as soon after occurrence as possible. 

Compensation for accidents under the Workmen's 
Compensation Act is frequently in the hands of the 
safety engineering department. The contact between 
this department and the health department is, there- 
fore, a close one. The safety engineer is constantly 
in conference with the doctors of the health depart- 
ment on matters of interest to each. Thus, the 
determination of an employe's ability to return to 
work rests with the health department, but the 
actual placing of the man at work and arranging for 
his compensation rests with the employment man- 
ager and safety engineer. 

The visiting nurse service is the connecting link 
between the employe's home and the factory. It 



INDUSTRY AND ORGANIZATION 11 

is an adjunct to the health department, but is run 
entirely independently. Its personnel consists of 
a chief nurse and one or more assistant visiting 
nurses. The duties of the service are : 

1. To investigate all cases reported by the health, 
employment or safety engineering department 
and report back to the inquiring department. 

2. To advise and assist those who are found in 
trouble. 

3. To do any temporary emergency nursing found 
necessary. 

4. To bring patients to the factory dispensary for 
dressings. 

5. To take up social problems of the home with 
employes and their families. 

6. To co-operate with the private physicians who 
are caring for employes at their homes. 

7. To visit the sick and injured employes when 
they are at a general hospital and bring them 
any benefit or compensation or other monies to 
which they are entitled. 

The visiting nurse service is in close contact with 
the employment, health, sanitation and safety engi- 
neering departments. The detail of its work will 
be given more thoroughly in another chapter. 

In large factories a satisfactory restaurant serv- 
ice is a necessity. This department is always a 
separate entity and consists of one or more lunch 
rooms at which cafeteria or served meals are pro- 
vided at cost. The type of food is usually simple 
and wholesome and the quantity sufficient. In some 
factories the service provides merely food to sup- 
plement the lunch men bring with them. In this 
case, coffee, milk, soup, fruit, cake and pastry are 



12 HEALTH SERVICE IN INDUSTRY 

served. In other factories a regular lunch of soup, 
meat, vegetable, dessert and coffee is served at a 
fixed price. Still another plan consists of providing 
an elaborate cafeteria similar to those found in busi- 
ness parts of any city. In all cases the cost of food 
to the employe is much lower and the quality higher 
than can be obtained outside of the factory. The 
lunch rooms vary from simple counters to elaborate 
and attractive dining rooms. The industrial physi- 
cian is frequently consulted as to the quality of the 
food, the health of the kitchen attendants, the clean- 
liness of the milk and other sanitary matters. 

Kecreation has become a regular feature in the 
life of the employe of a large factory. The depart- 
ment controlling recreation and athletics is often 
large and is always busy. The work which was 
done by the Y. M. C. A. in army camps with such 
success is now being duplicated on the factory 
grounds, and at the noon hour hundreds of men can 
be seen playing volley ball, pitching quoits, play- 
ing basket ball, or passing baseballs. Factories now 
have their representative teams like colleges, and 
even rowing has developed with extraordinary 
rapidity. The athletic interest is good for the mind 
as well as for the body, and a well regulated athletic 
program has a great effect in stabilizing labor and 
overcoming the physical fatigue and lassitude pro- 
duced by indoor factory work. 

The difficulty of obtaining satisfactory and 
hygienic living accommodations for the workers has 
induced many factories to build small but comfort- 



INDUSTRY AND ORGANIZATION 13 

able houses for its employes. The housing depart- 
ment is another of the departments which often 
calls upon the health or sanitation department for 
assistance and advice. 

Mutual benefit associations and a banking and 
loan service while of great importance to the worker 
are not departments in which the doctor is greatly 
interested except when he makes the examinations 
upon which the mutual benefit association settles its 
claim. 

It will be seen that the service division covers a 
distinctly medical field and that while it may not 
be administered by a doctor, medical advice is 
needed to some extent in almost every department. 
It is obvious that the service division only exists 
in large factories, but many of its principles are 
carried out even in factories of twenty-five or fifty 
employes. In fact, the basis of most of these activi- 
ties originated in the personal interest of the small 
shop owner in his workers. To quote from the 
preface of the service book of a large factory : 

"No work is done which the owner of a small 
shop would not do himself on a small scale as a 
matter of duty to his employes. Growth of the shop 
is almost invariably accompanied by loss of touch 
between the management and the workman. These 
departments are simply seeking to re-establish the 
good feeling and tolerance which have so much dimin- 
ished under modern management systems. Expe- 
rience has convinced us that this is an economic 



14 HEALTH SERVICE IN INDUSTRY 

measure entirely aside from improvement in morale, 
because it costs less to conduct these activities 
through a centralized department than to accom- 
plish the same thing by the effort of men whose 
whole time should be devoted to production." 



CHAPTER II 

THE MEDICAL NEEDS OF A SMALL FACTORY 

From the general discussion in the last chapter, 
it will be seen that various phases of the practice 
of medicine play an important part in the organi- 
zation of large factories. It is equally important 
in small factories which employ more than twenty- 
five men, but this importance has either not been 
recognized or the presumable expense has appeared 
too great. 

The overhead expense of running a small factory 
is frequently greater proportionately than that of 
a large plant. The absence of one or more employes 
is more keenly felt and may seriously inter ef ere 
with production, yet in the great majority no pro- 
vision for ascertaining or caring for the health of 
the worker is maintained. 

This is due partly to lack of knowledge on the 
part of the employer, partly to the difficulty of the 
problem, and partly to the insurance companies 
which cover the accident risk. The value of the 
doctor to industry has been recognized only recently 
and this recognition has been confined almost 
entirely to the large factories. The small manufac- 
turer has not considered his problems those of the 
larger plants, although he has without realizing it, 

15 



16 HEALTH SERVICE IN INDUSTRY 

in many cases, been personally acting as service 
manager in Ms factory. Because of his small per- 
sonnel lie has been able to keep in close touch with 
all of his workers, place them at the work for which 
they seem best fitted, and in case of sickness or 
accident, to see that proper attention was secured 
at once. With a small force the number of cases 
of sickness and accident are numerically so few that 
the regular employment of a doctor or nurse appears 
unnecessary. Accident insurance, which is now 
compulsory, in the majority of states, is usually car- 
ried through private insurance companies. These 
companies are forced to pay for any surgical treat- 
ment rendered in case of accident besides a definite 
compensation following a stated period of disability. 
In order to fulfill their obligations and obtain the 
shortest period of disability the insurance com- 
panies usually appoint selected doctors in each 
industrial center and ask their insurers to send any 
cases of injury occurring in the course of employ- 
ment to these doctors or in case of severe injury 
to send for one of them. The employer with his 
accident cases thus provided for feels that except 
for a first aid outfit at the factory no further pro- 
vision is required. Although this arrangement 
appears satisfactory, when stated as above, on closer 
view it shows many weak points. These can best 
be shown by outlining the medical needs of a small 
factory and seeing how well they are cared for at 
present. Listed they are as follows: 



MEDICAL NEEDS OF A SMALL FACTORY 17 

1. Knowledge of physical condition of employes at 
time of hiring. 

2. Knowledge of physical ability of employe to 
carry on the work to which he is assigned. 

3. Provision of sanitary working conditions, in- 
cluding light, heat and ventilation. 

4. Safeguarding the employes from special health 
hazards peculiar to the industry. 

5. Advising and giving emergency or simple treat- 
ment to sick employes. 

6. Giving prompt and adequate treatment in case 
of accident. 

Of these, the last only is provided under the pres- 
ent system and in this case the doctor is employed 
by the insurance company, not by the manufacturer. 

There are two methods which can be applied to 
carry out a complete system without great expense. 
The first consists of the employment of a part-time 
physician by the factory. The physician should live 
reasonably near the factory and should be at the 
factory a certain number of hours each week. The 
second method is a centralized employment depart- 
ment and dispensary, situated near the center of a 
group of small factories, which gives service to the 
group. Each plan will be considered in detail. 

In the first plan, the selection of the right doctor 
is most important. He must have knowledge, ability, 
tact with men, and a sound knowledge of the basic 
principles of medicine and simple surgery. More- 
over, he must be interested in the idea and consider 
his work at the factory as he would a much sought 
for hospital service. After the selection of a doc- 
tor he should be taken for a survey of the factory. 



18 HEALTH SERVICE IN INDUSTRY 

Specially dangerous spots and any poisonous proc- 
esses should be pointed out to him and he should 
be given a short talk upon the product manufactured 
and the machines by which the work is performed. 
This will give the doctor a chance to size up the 
sanitary and hazard situation and make his plans 
accordingly. Next, a small section of the shop 
should be assigned to the doctor as a dispensary. 
This space may be a small room formerly used for 
storage or may be made by partitioning off a sec- 
tion of floor space where it can be most readily 
spared. Excellent work can be done in very small 
quarters. For a factory of between one and three 
hundred men a room having a floor space of 200 
square feet separated into two parts by a partition 
at least seven feet high is ample. A first aid room 
of this size is required by law for factories employ- 
ing 100 or more employes in the State of Massa- 
chusetts. 

The equipment of such a room is not expensive. 
The following items are necessary : 

(a) A glazed sink with hot and cold water always 
available. 

(b) Electric, gas, or other suitable heating device 
and sterilizer. 

(c) A table with a smooth top. 

(d) At least two chairs. 

(e) A couch or bed, preferably the latter. 

(f ) Two woolen blankets. 

(g) Heavy rubber sheet IVz yds. square, 
(h) Two pillows, rubber covered, washable. 
(i) Two enamelled hand wash basins. 

(j) A waste pail. 



MEDICAL NEEDS OF A SMALL FACTORY 19 

(k) Individual drinking cups. 

(1) A rubber or metal hot water bottle. 

(m) A simple stretcher. 

(n) A medical and surgical kit. 

(o) A supply of individual towels. 

Having made his survey of the factory, personally 
met the foremen and the older workmen, and estab- 
lished his dispensary, the doctor should seek for a 
competent lay assistant among the workers. In 
factories employing two hundred or more, a regis- 
tered, trained nurse having some industrial train- 
ing should be installed on a full-time basis. In the 
smaller factories this expense is unnecessary and 
one of the workers can usually be found who has 
had some experience and interest in first aid work. 
This man should be given a course of intensive train- 
ing by the doctor, in which he is taught the proper 
method of cleaning a wound with gasoline and 
iodine, the sterile application of a compress, and 
proper bandaging. He should also be given a cer- 
tain amount of general instruction in first aid. Fol- 
lowing this, the doctor should call all the foremen 
together and give them a short talk on the ideas of 
industrial medicine, ending by a demonstration of 
the prone pressure method of resuscitation for elec- 
tric shock and a plea for interest and co-operation. 
The employer or superintendent should be present 
at this talk to show his support and impress the 
foremen with his interest in the work. 

From this time on all cases of sickness and acci- 
dent should be sent at once to the dispensary to be 



20 HEALTH SERVICE IN INDUSTRY 

treated by the first aid man or nurse. If the case is 
serious, the doctor is summoned, if not, he is treated 
simply and returns to work. The doctor pays regu- 
lar visits to the factory, once, twice, or daily each 
week, spending one or more hours, depending on 
the size of the plant. At this time he reviews the 
sanitary condition of the factory and reports to the 
superintendent any suggested changes or improve- 
ments. He next goes to the dispensary where he 
has sent to him any cases of sickness or accident 
which have occurred since his last visit, reviews, 
advises and gives any treatment necessary. 

After a month of this type of work he should begin 
the physical examination of the workers then 
employed, beginning with the foremen and older 
employes and omitting any who have any objection 
to being examined. The examination should be com- 
plete and should give the examined man a feeling 
of confidence in the thoroughness of the doctor's 
work. In this way, the workers are gradually exam- 
ined and each advised as to his physical condition. 
At the same time the doctor has an opportunity to 
advise a defective employe as to habits, diet, or any 
other change in his life which appears indicated. 
At this time also the doctor can arrange to take 
men off work for which they are not physically fitted 
and place them where they will be safer, without 
loss of wages. 

After all the regular force has been examined, 
new men taken on to fill vacancies can be examined 
shortly after hiring. Unless the doctor is at the 



MEDICAL NEEDS OF A SMALL FACTORY 21 

factory daily it is impossible for him to examine 
applicants for work before they are hired. 

Such a system has been carried on in a number 
of small factories with perfect success. It has been 
found that the workers appreciate the care they 
receive and that the prompt attention reduces the 
time lost from accident and sickness, keeps men at 
their work and improves the morale of the whole 
shop. There is no case recorded where a medical 
service has been dropped when once initiated. The 
insurance company is usually perfectly willing to 
co-operate by allowing the company to select its own 
doctor if he is a man of good standing, knowing 
that his effort will be to get men back to work early 
and to give the very best treatment possible. 

The method of medical supervision by a central- 
ized dispensary possibly connected with an Employ- 
ment Department is a method which has been used 
in the Middle West. The central dispensary is con- 
ducted by a group of doctors. Someone is always 
on duty and there are also nurses in attendance. 
A doctor is sent daily to each of the subscribing 
plants, supplementing the work of the full-time 
nurse or trained assistant, and carrying out the 
duties outlined for the physician by the first plan. 
When such a group of physicians includes special- 
ists and the work is carried on in a careful and 
scientific way there is no better method by which 
the small factory can supply its medical needs intel- 
ligently than by subscribing to such a service. 
Though theoretically such a service should be linked 



22 HEALTH SERVICE IN INDUSTRY 

with a central employment office which would employ 
for a group of factories, such a central employment 
office is seldom found. If these two services were 
grouped it would be possible for the small factory 
to receive almost as good a form of service as the 
large factory is now receiving from its own staff. 
The chief advantage from the medical standpoint 
would be the physical examination of applicants 
with proper placing, and the prevention of contagi- 
ous disease entering the factory. A medical group 
of the type just outlined is known as a Health 
Bureau. Shipley 3 gives the following synopsis of 
the work: 

"Such bureaus should be prepared to give to in- 
dustrial and mercantile concerns a well-balanced 
medical, surgical and sanitary service, which com- 
bines the emergency and preventive features in 
such manner as to produce the most effective re- 
sults at minimum cost. 

"The field force should be under the direction and 
immediate supervision of men qualified by vast 
experience in the fields of medicine and sanitation, 
in order to insure performance of technical service 
of the highest character. Furthermore, the staff at 
headquarters should be constantly analyzing the 
work performed by the field force, and planning 
and developing new and more effective means of 
securing results. This overhead service should be 
available to all of the establishments for whom the 
bureau is giving service, thus assuring to the 
smallest industry all the advantages which the 
largest corporation can secure through the employ- 
ment of full-time, high salaried industrial health 
directors. 

"The field force should include physicians, sur- 
geons, industrial hygienists and sanitarians, nurses 



MEDICAL NEEDS OF A S^IALL FACTORY 23 

and nurses' assistants, and home workers. When 
the needs of a factory have been determined, the 
service should be arranged so that maximum re- 
sults are obtained at minimum cost." 

Selby, in the course of his studies, noted that two 
factories, one employing 400 and the other 500 work- 
men, maintained full-time medical services and in 
one the average number of workmen per physician 
was about 200. The majority of small employers, 
however, do not make any attempt to furnish an 
:_uate medical service, and it is only by a stimu- 
lation of interest, health bureaus, afi described above, 
or state bureaus, that the employes of the small fac- 
tory will receive adequate care. Inasmuch as the 
number of factories employing under 1.000 workers 
is approximately 95 per cent of total number of fac- 
tories in the United States, the need is obvious. To 
quote from Selby: 

"In several cities are buildings in which small 
manufacturing concerns may rent apace and pur- 
chase power and light. Although the companies 
that usually avail themselves of these facilities are 
small, employing but few workmen, rarely more 
than a hundred, there may be in the aggregate 
1,000 or 2,000 employes to a building, a number 
that certainly justifies the maintenance of a dis- 
pensary and the employment of one whole-time 
physician, two nurses and a clerk. By prorating 
the cost among the companies., pexnans according to 
the numbers of their employes, the expense would 
be in proportion to their means, ye: they would 
have the use of a whole-time medical service and 



24 



HEALTH SERVICE IN INDUSTRY 





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CHAPTER in 

ORGANIZATION OF A MEDICAL DEPARTMENT IN A LARGE 

FACTORY 

In the first chapter it was shown that in large 
factories the health department is part of the serv- 
ice division. It is organized in such a way that it 
is in close contact with other departments of the 
service division, notably the employment and safety 
departments. 

The department is controlled by a chief physician 
who is responsible to the service director. The chief 
physician has as assistants one or more physicians 
and surgeons and a competent staff of nurses. This 
with clerical assistance comprises the basic per- 
sonnel. 

The work of the health department is carried on 
in one or more dispensaries depending on the size 
and shape of the factory. The largest of these 
dispensaries is placed next to the employment 
department and should be near the rooms assigned 
to the safety engineering department and the visit- 
ing nurses' service. 

The department is divided into three sections, each 
controlled by the chief surgeon. These sections are 
the health, sanitation and visiting nurse sections. 
Each section is separate and separately managed. 

25 



26 HEALTH SERVICE IN INDUSTRY 

The function of the health section is to preserve 
the health of the worker, to treat cases of accident 
and to prevent, diagnose and, to a certain extent, 
treat cases of sickness. 

The function of the sanitation section is to pro- 
vide and maintain the highest type of sanitation in 
the factory, co-operating in this with the engineer 
of the plant. 

The function of the visiting nurse section is to 
visit, advise and assist the worker at his home, espe- 
cially in case of sickness to himself or his family. 

The organization of these sections is shown on 
the accompanying chart. (Fig. 2.) 

The health section will be first considered. The 
equipment consists of a large, well equipped dis- 
pensary, centrally located, and, when the plant 
covers considerable territory, several sub-dispen- 
saries. The equipment of each dispensary is con- 
trolled by a registered graduate nurse. In the cen- 
tral dispensary are all records. 

Attached directly to the central dispensary or 
near it are an X-ray room, a dental department, and, 
if necessary, an oculist's room. 

The chief surgeon is in charge of the entire sys- 
tem and has as assistants at least one full-time and 
one or more part-time physicians and surgeons. 

In order to make a relatively accurate estimate of 
the needs of a plant, one nurse, at least, should be 
allowed to every thousand employes. In addition 
to the chief surgeon, one full-time doctor should 
be allowed for each two thousand employes. One 



LARGE-FACTORY MEDICAL DEPARTMENT 27 

dentist can care for about two thousand employes 
and one oculist can be assigned to four thousand 
employes, provided that special attention is not 
required by the hazard of the business. The ques- 
tion of specialists will be discussed fully in another 
chapter. 

The health section records are kept by one or 
more lay clerks who are to some extent assisted 
by the nurse or nurses in the main dispensary. 

The division of the work of the personnel is usu- 
ally as follows: The chief surgeon has his office 
in or near the main dispensary. At this dispensary 
are stationed all assistant doctors, and at least one 
nurse. As previously stated, all records and files 
are grouped at the main dispensary. At each sub- 
dispensary are stationed one or more nurses, de- 
pending upon the activity of the work. 

The health department has for its functions : 

1. The physical examination of all applicants for 
positions in the factory. 

2. The re-examination of all employes transferred 
from one department to another. 

3. The periodic examination of workers employed 
in departments where there is a health hazard. 

4. A periodic examination of all workers who have 
physical defects needing following up. 

5. The placing of physically defective workmen in 
departments where the work will not prove in- 
jurious. 

6. The diagnosis and, in certain cases, the treat- 
ment of workers applying to the dispensary for 
medical care. 

7. Co-operation where possible with the family 
physician of sick and defective employes. 



28 HEALTH SERVICE IN INDUSTRY 

8. Diagnosis and treatment of workers injured 
during employment. 

9. Diagnosis and in some cases treatment of work- 
ers having surgical conditions not the result of 
employment. 

10. Spreading health publicity by lectures, leaflets 
and similar publications. 

The effectiveness with which this is done depends 
largely npon the initiative and vision of the chief 
surgeon. It is his duty to co-ordinate the work of 
the health department with that of the contact de- 
partments mentioned in the first chapter, to stimu- 
late in his assistants scientific and accurate work, 
and to co-ordinate and render effective the work of 
his own department. In addition to this he must 
do a great deal of actual work, particularly along 
diagnostic lines. In some very large factories, em- 
ploying over ten thousand employes, the work of 
the chief surgeon is largely administrative, but in 
the average large factory where the number of 
employes varies between three and five thousand, 
a great deal of actual work must be done. 

The management of the health of the employes 
qf a large factory is carried out somewhat as fol- 
lows: Each applicant for work after having been 
interviewed by the employment department is sent 
to the health department for a complete physical 
examination. Following this examination the appli- 
cant is classified by the examining doctor as to his 
ability to work. The classification is usually con- 
fined to four groups. A man who is normal in every 
way is classified in the A group; a man who has 



LARGE-FACTORY MEDICAL DEPARTMENT 29 

several slight defects, none of which are severe, is 
classified in the B group; a man who has defects 
severe enough to make his employment in certain 
departments inadvisable is classified in the C group ; 
while an applicant whose condition renders it unwise 
to work in any department is classified in the D 
group. Few men fall in this classification. Bur- 
lingame has made it a rule to classify as D all men 
whose employment would be dangerous to them- 
selves, to others, or to property, a most satisfac- 
tory and neat classification. The number of these 
workers is, fortunately, few. According to Mock, 
the number amounts to 10 per cent of those apply- 
ing, but in the average factory, where there is a 
variety of work and no great hazards, as in a 
machine shop, the number will be found to be about 
2.8 per cent of those approved by the employment 
department. The disposition of these men can and 
should be made, whenever possible, by the examin- 
ing physician. Thus, a case of active tuberculosis 
is obviously a danger to himself and others in a fac- 
tory and should be advised to make immediate appli- 
cation at the nearest tuberculosis clinic for care 
and advice. To simply reject such a man without 
telling him of his condition and advising him what 
to do is a social crime, exposing others to the dis- 
ease and preventing the possible cure of the affected 
man. 

But to return to the physical examination. After 
the examination has been completed and the worker 
classified, he is sent back to the employment depart- 



30 HEALTH SERVICE IN INDUSTRY 

ment with his letter classification. If the worker is 
an A or B class man, he is at once put to work. If 
his classification is C, he is held at the employment 
department nntil the doctor is able to confer with 
the employment manager as to the type of work 
for which the applicant is best fitted. In some fac- 
tories besides classifying the applicant when he is 
in the C class, the doctor writes a prescription for 
the type of work desired. This prescription the 
applicant takes with him to the employment depart- 
ment, and from it the employment manager deter- 
mines the work at which the applicant shall be put. 
It is considered advisable that the same relation 
of doctor and patient be maintained as strictly in 
industry as in private practice. The doctor should 
discuss the type of work the patient can and can- 
not do with the employment manager, but not the 
physical condition necessitating it. 

The results of the physical examination are 
recorded on a special card, envelope, or sheet by 
the examining physician and this is then filed with 
the rest of the records. This card forms the basis 
of all future medical work upon the employe and 
is frequently referred to. 

As a result of the physical examination, all work- 
ers are classed broadly into two divisions, stand- 
ard and sub-standard. The sub-standard workers 
are placed at work for which they are physically 
fitted through the employment department. Their 
physical examination cards are flagged with a col- 
ored signal indicating the defect. Once in three 



LARGE-FACTORY MEDICAL DEPARTMENT 31 

months these defective men are re-examined to see 
how they are standing np under their work, and any 
adjustments made in their work which appears nec- 
essary. At this re-examination the examining physi- 
cian discusses with the worker the condition found 
and advises him. All men working where there is 
an industrial disease hazard are similarly managed, 
each one being called to the main dispensary quar- 
terly and rigidly examined for signs of industrial 
disease or poisoning. This also gives the physician 
an opportunity to discuss freely with the worker the 
best methods of caring for his health. 

All workers, standard or sub-standard, are re-ex- 
amined on transfer from one department to another. 
This gives the Health Department an opportunity 
to check up any changes in the workers' condition 
and prevents a sub-standard worker from being 
transferred to work for which he is not physically 
fitted. 

The applicant having become a worker comes 
under the medical supervision of the Health Depart- 
ment. This supervision is carried on as follows : 

All workers when they start at work are shown 
the nearest dispensary and instructed to report 
there for any sickness or injury, no matter how 
slight. 

If this is one of the branch dispensaries the fol- 
lowing routine is carried out in case of sickness or 
accident : 

1. Employe notifies foreman of sickness or acci- 
dent. 



32 HEALTH SERVICE IN INDUSTRY 

2. Foreman directs employe to nearest dispensary. 

3. Nurse at dispensary takes short history of case 
and examines into condition complained of. 

4. If the condition is simple, as a scratch or con- 
stipation, the condition is treated and patient 
told to report back next day. 

4a. If the condition is severe the patient is sent to 
the central dispensary for diagnosis and treat- 
ment, or a doctor is sent from the central dis- 
pensary for this purpose. 

5. The case is entered on a card or slip which is 
forwarded to the central dispensary for filing 
and notation. 

6. Patient's name, number and department are 
entered in a book; and a note made as to the 
day the patient should return to the dispensary 
for treatment. 

7. Patient returns to work or in case of a serious 
accident or sickness is sent home or to a hos- 
pital. 

7a. If patient is sent home or to a hospital, the vis- 
iting nurse service is notified. 

8. When patient returns for retreatment, what is 
done is recorded, another notation is made in 
the book, and date when patient should return 
unless discharged is entered. 

This in brief is the routine used in treating cases 
of sickness and accident occurring in the factory. 

In order to obtain uniform results, routine meth- 
ods of treatment have been adopted wherever pos- 
sible. This applies more particularly to accidents, 
but it is also possible in treating minor cases of 
sickness. The methods adopted and the reason for 
them will be more fully outlined in a later chapter. 

Certain routine methods of report to contact de- 
partments have also been found necessary. These 



LARGE-FACTORY MEDICAL DEPARTMENT 33 

will be considered fully under the chapters dealing 
with the care of sickness and accident. 

Sanitation is the second branch of the medical 
department coming "under the control of the chief 
surgeon. Sanitation consists of the control of the 
following plant conditions : 

Light Water 

Heat Toilets 

Ventilation Looker P.xms 

Dusty Conditions General Cleanliness 

Each of these will be discussed at length in the 
chapter on sanitation. The management of sani- 
tation throws the chief surgeon in close contact with 
:he plant's engineer, as many of the problems are 
those of engineering. The control of sanitation in- 
volves tours of inspection at regular intervals. 

The Sanitation Department is administered by 
a foreman who has under him a corps of workers. 
The organization is similar to that of any factory 
department. The entire plant is divided into zones, 
and a certain number of workers are assigned to 
each zone, each one having a regular task. Thus, 
one man will take charge of the cleaning of a cer- 
tain amount of floor space, another will care for 
the toilets and locker rooms, another will clean win- 
dows, while still another will collect and clean cus- 
pidors if these are necessary. The sanitary work- 
ers in each zone are controlled by a sub-foreman 
who reports directly to the sanitary foreman.. 

It is well to supplement the inspections made by 
the chief surgeon with weekly reports made by the 



34 HEALTH SERVICE IN INDUSTRY 

Norton Company Worcester, Mass. 

WEEKLY SANITATION REPORT 



Dept- 



Date_ 



LOCATION 


CONDITION 


Locker Rooms 




Toilet 




Floor 




Corners 




Windows 




Cuspidors 




Waste Cans 





Remarks : 



If everything is satisfactory it is only 
necessary to write "O. K." in this space 



Signed. 



Foreman 
NOTE : To be filled out and sent to Service Director each Monday 

Fig. 3. SANITATION REPORT 

This Is Made Out Weekly by Each Foreman and Forwarded to 

the Chief Physician 



LARGE-FACTORY MEDICAL DEPARTMENT 35 

production foreman of the various departments. 
(Fig. 3.) 

Visiting Nurse Service is the third branch of the 
medical department. 

The object of this service is to follow up at their 
homes, employes who are out because of sickness, 
accident, or sickness in the family. As soon as a 
case of sickness or accident is sent home by the 
health service, the Visiting Nurse service is notified 
and a visiting nurse visits the patient at his home. 
The object of these visits is more to render assist- 
ance than to do actual nursing, though in many 
large factories where there is a large force of visit- 
ing nurses, actual nursing is done. When a district 
nurse service exists in the community, it is not 
necessary for the factory nurse to do much actual 
nursing, though she should be prepared to take care 
of any emergency she finds. Her main function is 
to see that the patient has good surroundings and 
improve these if possible; to secure a physician or 
nurse if the patient is in need of one, or to send or 
transport the patient to a hospital if the patient 
is willing and surroundings are bad. 

The visiting nurse also visits cases of accident 
who are at the general hospital and reports back 
their condition to the chief surgeon. In short, the 
service is a contact between the sick or injured 
workers and the health department. 



36 



HEALTH SERVICE IN INDUSTRY 




Fig. 4. N. A. S. 0. FIRST AID JAR 
Adopted as Standard by Many Large Factories 



CHAPTER IV 



FACTOKY DISPENSAEIES 



The factory dispensary is the center for all medi- 
cal work and should be situated as near the geo- 
graphical center of the factory as possible. Like 
the base hospital in the army, it acts as the final 
point for diagnosis and treatment, and is supplied 
by the sub-dispensaries which correspond to the 
army field hospitals. The sub-dispensary in turn 
is supplied from the factory department first aid 
stations if the factory is large enough to require 
these. 

The first aid station will be the first thing con- 
sidered. It is usually represented by a box or jar 
which contains a few sterile gauze pads, Tr. of 
Iodine, burn ointment, and a tourniquet. This box 
is the equipment of the trained first aid man, usually 
a foreman or sub-foreman. Up to a few years ago 
these boxes, usually containing dirty bandages, some 
patent so-called " antiseptic,' ' and a pair of rusty 
forceps, probably caused more infection than they 
prevented. Absorbent cotton was liberally used. 
Iodine or even soap and water shunned. Of recent 
years, however, all this has been changed and where 
the first aid box remains it is usually well kept 
up. The American Red Cross and the war train- 

37 



38 HEALTH SERVICE IN INDUSTRY 

ing received by many of the factory operatives have 
combined to diffuse a large amount of sane, practi- 
cal knowledge among the workers of the country, 
and the results are gratifying. 

The best first aid outfit at present is that devel- 
oped by the Conference Board of Physicians in 
Industry and adopted by the National Founders 
Association. (Fig. 4.) It consists of a heavy glass 
jar in a wooden case with the following contents : 

1 Tourniquet 

1 pair Nickel-Plated Scissors 
1 pair Nickel-Plated Tweezers 
1 Triangular Sling 
1 Wire Gauze Splint 
12 Assorted Safety Pins 

1 2-oz. bottle Castor Oil 

2 3-oz. tubes Burn Ointment 

1 2-oz. bottle 3 % Alcoholic Iodine 

1 2-oz. bottle White Wine Vinegar 

1 2-oz. bottle 4 % Aqueous Boric Acid 

1 2-oz. bottle Aromatic Spirits of Ammonia 

1 2-oz. bottle Jamaica Ginger (or substitute) 

1 piece of Flannel 24" x 36" 

1 roll Absorbent Cotton (1.5 oz.) 

1 roll 3" x 10 yards Gauze Bandage 

1 roll 2" x 10 yards Gauze Bandage 

2 rolls 1" x 10 yards Gauze Bandage 

1 spool 1" x 15 yards Adhesive Plaster 
6 sealed packages 6" x 36" Sterile Gauze 
1 Teaspoon 
1 Metal Cup 

1 Medicine Glass 

2 Medicine Droppers 

3 Paper Drinking Cups 
First Aid Record Cards 

The advantages of a jar are that it is clean, the 
equipment can be seen at a glance, it can be used 



LARGE-FACTORY MEDICAL DEPARTMENT 39 

to carry water. The instructions are incorporated 
in the glass cover. The Department of Hygiene of 
the New York Department of Labor has approved 
the N. A. S. 0. Standard First Aid Outfit for 
Employes in the State of New York in lieu of the 
First Aid Outfit required by the department and 
similar action has been taken by the Massachusetts 
Department of Labor and Industries.* 

The jar or box is in the hands of a trained lay- 
man who has been carefully taught to do little but 
do thatrlittle well. The following list of instruc- 
tions thoroughly understood is sufficient^ 

Open Wounds — Abrasions, Cuts, Punctures 

Drop 3% Alcoholic Iodine into wound freely, 
then apply dry sterile gauze to wound and bandage 
it. If necessary to cleanse greasy substances from 
wound, flush it with gasoline. Do not otherwise 
cleanse wound. 
Severe Bleeding 

Place patient at rest and elevate injured part. 
Apply sterile gauze pad large enough to allow pres- 
sure upon, above and below wound. Bandage 
tightly. If severe bleeding continues apply tourni- 
quet between wound and heart and secure physi- 
cian's services at once. Use tourniquet with cau- 
tion and only after other means have failed to stop 
bleeding. 

Nose Bleeding 

Maintain patient in an upright position with 
arms elevated. Have him breathe gently through 
mouth and not blow nose. If bleeding continues 
freely, press finger firmly on patient's upper lip 
close to nose or have him snuff diluted White Wine 
Vinegar into nose. 



*The N. A. S. O. First Aid Jar can be obtained from National Founders 
Association, 29 South La Salle St., Chicago, 111. Price $7.25. 



40 HEALTH SERVICE IN INDUSTRY 

Bruises, Sprains 

Cover injury with several layers of sterile gauze 
or cotton, then bandage tightly. Application of 
heat or cold may help; other means are unneces- 
sary. If injury is severe place patient at rest and 
elevate injured part until physician's services are 
secured. 
Eye Injuries — Except Eye Burns 

For ordinary eye irritations flood eye with 4% 
Boric Acid Solution. Remove only loose particles 
which can be brushed off gently with absorbent 
cotton wrapped round end of toothpick or match 
and dipped in Boric Acid Solution. 

Do not remove foreign bodies stuck in the eye. 
In that case and for other eye injuries drop castor 
oil freely into eye, apply sterile gauze, bandage 
loosely and send patient to physician. 
Splinters or Slivers Embedded in Skin Except Eyes 

If easily reached withdraw with tweezers, then 
treat as "Open Wounds"; otherwise let physician 
attend to it. 
Eye Burns, Fire and Electrical Burns and Sunburn 

Do not open blisters. Use burn ointment (3% 
Bi-Carbonate of Soda in Petrolatum) freely on 
sterile gauze applied directly to burn. Cover with 
several thicknesses of flannel or other soft mate- 
rial, then bandage, but not tightly. 
Acid Burns 

Thoroughly flush wound with water, then dry 
wound, apply burn ointment and bandage as above. 
Alkaline Burns 

Thoroughly flush wound with water, then flood 
with White Wine Vinegar to neutralize (dilute 
vinegar for alkaline eye burns), dry wound, apply 
burn ointment and bandage as above. 
Dislocations 

In case of dislocation of finger, except second 
joint of thumb, grasp finger firmly and pull it 



FACTORY DISPENSARIES 41 

gently to replace joint, then place finger in splint 
and bandage it. In all other cases place dislocated 
part at rest and promptly secure physician's 
services. 
Fractures 

Make patient comfortable and secure physician's 
services at once. Avoid unnecessary handling to 
prevent sharp edges of broken bones tearing 
artery. If patient must be moved place broken 
limb in as comfortable position as possible and 
secure it by splint. In case of severe bleeding 
apply sterile gauze and follow directions under 
"Severe Bleeding." 
Dizziness, Headache, Nausea 

Give patient teaspoonful of Aromatic Spirit of 
Ammonia in hot or cold water. 
Chills, Cramps 

Give patient 20 to 30 drops of Jamaica Ginger in 
hot or cold water. If improvement is not speedily 
obtained send for physician. 
Frost Bites 

Rub with ice, snow or cold water, then treat as 
fire burns. 
Internal Poisoning 

Immediately secure physician's services. Make 
patient drink large quantities of water, preferably 
warm, and make him vomit by sticking your finger 
down his throat or by other means. 
Heat Prostration 

Give patient teaspoonful of Aromatic Spirit of 
Ammonia in hot or cold water. In case body feels 
warm apply cold to it; if necessary give cold bath. 
In case body feels cold and clammy, apply heat to 
it and immediately send for physician. 

Unconsciousness from Fainting 

Lay patient on his belly and turn his face to 
one side. Loosen all tight clothing. Remove false 
teeth, tobacco, etc., from mouth. Apply cold to 



42 HEALTH SERVICE IN INDUSTRY 

head, warmth to hands and feet. If breathing 
stops treat patient as directed under "Electric 
Shock." Give no liquids by mouth until patient is 
fully conscious. Then give teaspoonful of Aro- 
matic Spirit of Ammonia in hot or cold water. 

Shock, Following Injury 

In case shock is due to severe bleeding control it 
first as directed under "Severe Bleeding" and sum- 
mon a physician. Lay patient flat on back and 
keep him warm with blankets, hot-water bottles, 
etc., and provide plenty of fresh air. Let patient 
inhale fumes of Aromatic Spirit of Ammonia. If 
fully conscious give hot drink or teaspoonful of 
Aromatic Spirit of Ammonia in hot or cold water. 

Unconsciousness from Asphyxiation by Gas, Smoke 

or Water 

Treat patient as directed under "Electric Shock." 
Electric Shock 

Immediately free patient from electrical circuit, 
using every care to protect yourself against electric 
shock. Then if patient is unconscious, even if he 
appears dead, lay him on his belly with arms ex- 
tended forward, turn his face to one side, remove 
false teeth, tobacco, and so forth, from his mouth 
and draw his tongue forward. 

Kneel, straddling patient's thighs, facing his 
head, and resting your hands on his lowest ribs. 
Swing forward and gradually bring weight of your 
body upon your hands and thus upon patient's 
back, then immediately remove pressure by swing- 
ing backward. Repeat this movement about twelve 
times per minute without interruption for hours if 
necessary, until natural breathing has been started 
and maintained. 

The sub-dispensary as already stated is a small 
dispensary for the treatment of accidents and minor 
sickness. It is under the charge of a trained, regis- 



FACTORY DISPENSARIES 43 

tered nurse. In small factories it is the only dis- 
pensary necessary. 

The dispensary should contain not less than 200 
square feet floor space. If it is the only hospital in 
the factory it should be provided with a partition 
separating certain portions of the room. This par- 
tition should be at least seven feet in height and 
should contain a door. The floor and walls of the 
dispensary should be smooth, and the floor of some 
impervious material. The room should be ventilated 
directly to the outside air by a window or other suit- 
able opening or approved exhaust system. 

The dispensary should be centrally located in 
regard to the territory it is to supply and when pos- 
sible should be so placed as to guarantee a maximum 
of quiet and privacy to those requiring first aid 
treatment or rest, as well as readily accessible to 
the persons for whose accommodation it is designed. 

The equipment need not be elaborate. The fol- 
lowing inventory was taken from a sub-dispensary 
in a factory which has been maintaining medical 
supervision of employes for ten years. 

1 Table 

2 Cupboards 

1 Dressing Table — 3 glass shelves 

1 Swivel Chair 

1 High Chair — Glass Arm (for dressings) 

1 Flat Instrument Basin 

1 Kidney Basin 

1 Large board for folding gauze 

1 Electric Sterilizer 

1 Saw Horse 

1 Pus Pail 



44 HEALTH SERVICE IN INDUSTRY 

1 Board for Adhesive 

1 Army Stretcher 

1 Steel Locker (2 coat hangers) 

1 Metal Basket 

1 Irrigating Can, 5' 

2 Small Cupboards, 2 gl. Shelves 

1 Solution Stand with 3 gl. Shelves 

1 Solution Basin, glass cover 

2 Hand Basins 

1 Bedside Screen, cover 

1 Razor Strap 

1 Emergency Jar with sponges 

1 Splint, Tourniquet, aro. spts. 

1 Cot 

1 Mattress 

1 Pillow 

2 Blankets 

1 Rubber Sheet 
1 Desk Clock 

1 Folding Chair 

3 Cane Seated Chairs 
5 Bottle Racks 

2 Sheets 

2 Pillow Cases 

5 Eye Bottles and Eye Droppers 

1 Razor 

2 Scalpels 

4 Forceps 

3 Scissors 

1 Haemostats 

1 Bandage Scissors 

1 Large Scissors for Gauze 

1 Glass Hypo. Syringe and Needles 

The dressings include the following: 

Sterile Gauze Bandages 

Adhesive Plaster, 5 yds. x 1 foot rolls 

1 package of wooden splints 

Sheet Wadding 

1 Thomas Splint, U. S. Army Model 



FACTORY DISPENSARIES 



45 



Tin Cross Pieces for finger splints 

Wooden Applicators 

Tongue Depressors 

Various boxes and bottles for holding equipment 

The drugs include the following: 



Chlorozene 

Collodion 

Creso-pinol 

Gasoline 

Lead Acetate and Alum 

Tincture of Iodine 

Wax 

Acetanilid 

Alcohol 

Alum (powder) 

Ammoniated Mercury 

(oint.) 
Arom. Spirits of Ammonia 
Bichloride of Mercury 
Bismuth Subnitrate 
Blaud's Pills 
Boric Acid (ointment) 
Boric Acid (powder) 
Brown Mixture 
Browntail Moth Lotion 
Capsolin 
Castor Oil 

Chloroform and Cloves 
Cocaine (4% sol.) 
Compound Cathartic pil. 
Compound Rhubarb pil. 



Dover's Powder 

Essence of Peppermint 

Ether 

Ethyl Chloride 

Glycerine 

Glycerine and Iodine 

Headache Anodyne 

Lassar's Paste 

Rhinitis Tablets 

Rhubarb and Ipecac Tabs. 

Rochelle Salts 

Scarlet Red Ointment 

Seidlitz Powders 

Setter's Gargle 

Silvol 

Soda Bicarbonate 

Soap Liniment 

Sodium Salicylate 

Special Cough Mixture 

Special Eye Drops 

Tartaric Acid 

Tincture of Benzoin 

Tincture of Ginger 

Yellow Oxide of Mercury 

Zinc Oxide (oint.) 

Zinc Stearate (powder) 



The cost of the above equipment was about $250 
before the war and now amounts to about $400. 
With the exception of the drugs and supplies the 
equipment should last five years before replacements 
to any extent are necessary. 



46 HEALTH SERVICE IN INDUSTRY 

The equipment standardized and approved by 
the Conference Board of Physicians in Industry is 
as follows: 

1 metal combination dressing table with drawers 

to hold instruments and dressings 
1 metal chair with head and arm rest 
1 metal stool built in combination with metal waste 

can 
1 small wooden or metal examination table with 

pads, with ends hinged to drop down 
1 stretcher of the army type (canvas stretched 

over two round wood poles) or of the metal 

N. A. S. O. type 
1 small instrument sterilizer arranged for electric, 

gas, alcohol or kerosene burner 
Y2 dozen utensils, such as arm and foot basins, 3 or 
4-quart ordinary basins, 2-quart dipper, bed 
pan, etc. 
1 portable first-aid outfit (N. A. S. O. standard 

first-aid jar recommended) 
Appropriate instruments, including a razor 
Dressings, splints, drugs 

Eecently, the American College of Surgeons has 
been interesting itself in Industrial Surgery and is 
considering a recommended minimum equipment. 

The central or main factory dispensary is some- 
times called the clinic. As has been pointed out, it 
is the medical center of the factory and is operated 
by doctors and nurses. It is also the proper place 
for all records. It should be near the chief sur- 
geon's office, and close to the X-ray room, pathologi- 
cal, dental and eye departments. The size and 
arrangement depends on the size of the factory. In 
such a great factory as the Ford Motor Company 



FACTORY DISPENSARIES 47 

in Detroit, not only is all emergency operating done 
at the plant hospital, but wards are ready for the 
reception of patients. The merging of a ward with 
the central dispensary is, however, rare and only 
confined to very large factories or to those which 
are at a long distance from a general hospital. 

There are certain general principles concerning 
factory dispensaries which are of interest. First 
there should be no waiting room. The object of the 
dispensary is to return the sick or injured man to 
work at the earliest moment. It is necessary to give 
rapid and good service to do this, but it is much 
better economics to have more nurses or more dis- 
pensaries than to keep anyone waiting. Six good 
workmen waiting for dressings can cost the com- 
pany much more than the nurse's salary in a very 
few days. The dispensary should, therefore, not 
only have no waiting room, but be so arranged that 
maximum speed in dressings and handling cases 
can be obtained. This is done by using a unit system 
of grouping. The medical and surgical sections of 
the dispensary should be separate and distinct. 
They will be described in detail. 

The medical section of the dispensary is arranged 
so that workers may have an opportunity to consult 
the doctor with a certain amount of privacy, to have 
physical examinations, and to receive any advice 
and immediate treatment required. The medical 
section should therefore contain an office or parti- 
tioned space with a desk for the doctor and chair 
for the patient. There should be at least one booth 



48 HEALTH SERVICE IN INDUSTRY 

where the patient may be examined. Connected 
with this section there should be a recovery room 
with one or two beds where men who have an 
acute attack of sickness may rest, or an abdominal 
examination be made. A medical cabinet or set of 
shelves is necessary for holding the drugs, ther- 
mometers, urine bottles, and so forth. 

The medical section has nothing whatever to do 
with the physical examination rooms where appli- 
cants for positions in the factory are examined. It 
is the purely medical part of the dispensary and 
should be considered only as a medical and diag- 
nostic center. 

The surgical section is separated directly by a 
partition or indirectly by an open space from the 
medical section. 

Its work is divided into several different types 
and for this reason a careful arrangement by units 
will greatly reduce and simplify the work. A unit 
consists of all the appliances, apparatus and dress- 
ings needed for a certain type of surgical work. 
Each unit is so arranged that the doctor or nurse 
can reach the part to be treated, dressings and in- 
struments, with the least possible lost motion. 

The usual units consist of 

1. Units for dressing clean wounds of the hand 
and forearm. 

2. Units for dressing clean injuries of the foot 
and leg. 

3. Units for dressing infections. 

4. A unit for treatment of ear, nose and throat 
cases. 




Fig. 5. A UNIT TABLE SET UP FOR HAND DRESSINGS 

Contents of Upper Shelf 

Left to Right 

1. Bandages 1 in. and 2 in. 

2. Tr. Iodine in glass stoppered bottle. 

3. Thumb forceps in antiseptic solution. 

4. Gasoline. 

5. Sterile cotton swabs on wood applicators. 

6. Sterile gauze 2x2 in. 

7. Bandage scissors. 

On side of table strips of adhesive. It is better to have these 
spread on a bread board. 



FACTORY DISPENSARIES 49 

5. A unit for treating eye cases, especially foreign 
body in the eye. 

6. A unit for treating burns. 

7. Units for the treatment of back strains. 

8. A unit for the treatment of patients who must 
undress. 

Unit for dressing clean wounds 
of the Hand and Forearm. (Fig. 5.) 

a. One chair for patient, usually built high so 
that the dresser does not have to bend over. The 
chair is of the cafeteria type, having a broad arm 
which is covered with a glass plate or white enamel 
ware. 

b. A small glass or metal topped table upon 
which are the following: 

Top of Table 

One wide-mouthed glass stoppered bottle contain- 
ing Tr. Iodine, U. S. P., Y2 or full strength, four 
ounces. 

One wide-mouthed glass stoppered bottle contain- 
ing Benzene or Gasoline, 8 ounces. 

One wide-mouthed bottle containing Lysol or 
other aseptic solution in which one pair thumb for- 
ceps without teeth is immersed, handle projecting. 

One wide-mouthed bottle containing sterile cot- 
ton swabs on wood applicators. 

One metal box with cover containing folded 
sterile gauze compressors, 2x2 in. 

One pair of bandage scissors. 
Shelf of Table 

One dozen 1-in. gauze bandages. 

One dozen 1^-in. gauze bandages. 

One dozen tin cross finger protectors. 

The above can easily be contained in a low- 
sided tray. 
Standing near or resting on lower shelf of table 

One bread board covered with strips of adhesive 
plaster, % in. wide by 2 ft. long, for reinforcing 
dressings. 



50 HEALTH SERVICE IN INDUSTRY 

Unit for dressing clean injuries 
of the foot and leg 

a. One ordinary chair of metal or wood. 

b. One leg rest of wood, usually horse type. 

c. One table with same arrangement as clean 
hand dressing table except that lower shelf should 
contain a jar of zinc oxide ointment, and adhesive 
strips should be IY2 in. wide by 2 ft. long. 

Unit for dressing infections 

One ordinary chair. 

One table as before but with following dressings : 

One bottle Alcohol 

One bottle Ether 

One bottle Dichloramin T. 

One jar of 4x4 in. gauze 

Sponges soaking in Chlorazene or other antisep- 
tic solution 

One package of thin oil, sandwich paper or celu- 
silk. 

Assorted bandages 

Cotton sponges in retainer 

Instruments 
Two pair Kelly Clamps 
One pair Bandage Scissors 
One pair Thumb Forceps in antiseptic solution 

Unit for Treatment of Ear, Nose and Throat Cases 
(This can often be combined with unit for treat- 
ing eye cases) 

One table as before 

One specialist's chair 

One strong focusing light 

One head mirror 

One bottle Tr. of Iodine and Glycerine, equal 
parts. 

One bottle Silvol or Argyrol 25%. 

One set nasal and throat sprays in rack with 
solutions. 

One compressed air tank 



FACTORY DISPENSARIES 51 

One metal irrigating can, 2 qts., with attach- 
ments 

One pus basin 

Instruments 
One nasal speculum 
One set aural specula 
One ear curette 
One ear or nasal forceps 
Absorbent Cotton 

Unit for Treating Eye Injuries 

A dark room 5x5 feet, inner walls painted black 
Special bracket with light 
Specialist's chair 

Shelf for eye solutions in dropper bottles 
Two cataract knives, eye spuds, etc. 
Watchmaker's glasses or bifocal magnifying 
glass 

Sterile gauze 
Waste bucket 

Unit for Treating Burns 
Table as before 

One jar Gauze Sponges 4"x4" soaking in satu- 
rated solution of Sodium Bicarbonate 
Apparatus for wax treatment 
Rolls of sheet wadding 

Units for Back Strains and 
for Patients who must undress 

Booths 6x6 feet with a swing door. A hole cut in 
door enables doctor to see when patient is ready. 

Each booth should have a table equipped as 
unit one. 

In addition there should be an electric plug so 
that heat-treating apparatus can be connected. 

The physician should use his own judgment as to 
the type of apparatus desirable. 

Broad straps of adhesive ready cut on a bread 
board for back strapping are desirable. 



52 HEALTH SERVICE IN INDUSTRY 

In addition to the units there must be an adequate 
number of sinks or basins with running hot and cold 
water. These sinks can well be placed in the center 
of the dispensary to be easily reached from all sides. 
When sinks are used instead of hand basins, white 
enameled basins placed inside the sink and kept in 
an antiseptic solution when not in use, are of value. 
There should also be one or two foot tubs available. 
The sterilizer should be centrally located and easily 
accessible from all parts of the surgical section. It 
should consist of a large dressing sterilizer and a 
medium sized instrument sterilizer. A container for 
sterilizing water is unnecessary and occupies valu- 
able space. Near the sterilizer should be placed the 
instrument cabinet which contains instruments and 
frequently needed supplies. The cabinet need not 
be elaborate nor very expensive. Near each dressing 
table should be a receptacle for soiled dressings. 
There are many types of receiver in use. Selby 
describes an innovation which is strictly clean and 
not an eye sore. This is a " paper receptacle used 
in the dispensary of the Erie Forge Company, a 
cylindrical bag supported by a light metal stand." 

At each sink there should be a towel shelf and 
soiled towel receptacle. This may be a cotton bag 
suspended from a metal ring or a hamper. 

Many variations of arrangement of these units 
are now in use and there are numerous modifica- 
tions. The General Electric Company in its West 
Lynn plant has a central dispensary with surgical 
arm and hand units in the form of a long bench with 



FACTORY DISPENSARIES 53 

arm rests covered with glass. Beneath each seat is 
a board which can be pulled out for a leg rest. On 
the back of each seat is a coat and hat rack. 

Many other instances of ingenious arrangements 
might be cited but the principle of " units for treat- 
ment" remains unchanged. 

It has been previously stated that the records of 
the medical and surgical work done at both branch 
and central dispensaries should be centralized at the 
main dispensary. Every factory medical service 
has its own method of making and filing records. 
There is no one best method as yet decided on. The 
record system will be discussed in a later chapter. 



CHAPTER V 

THE INDUSTRIAL PHYSICIAN AND THE INDUSTRIAL NURSE 

The industrial physician must be a good general 
medical man and have had a hospital training in 
traumatic surgery. He must have executive ability 
and be able to handle men. In addition to this he 
must have interest in and sympathy for his patients, 
injecting the soul of the family doctor into his work. 
As a very prominent physician put it, the factory 
will get more from a 60% trained man with 100% 
interest and personality than from a 100% trained 
man with 60% personality. Geier 5 thus describes the 
industrial physician : 

' ' The industrial physician is that man who gives 
up his private practice to enter industry for the 
purpose of using his knowledge of medicine and 
surgery to serve the worker and the management. 
Here again, just as in private practice, the man is 
going to be a relative failure or a great success, 
depending upon his ability and upon the extent to 
which he now qualifies as a specialist in this new 
subject. He may be the type of man that is satisfied 
merely to dress injuries and simply to prescribe for 
men who appear in his office; or he may make a 
thorough study of the plant conditions, the sanita- 
tion, safety, etc., for the purpose of creating a better 

54 



INDUSTRIAL PHYSICIAN AND NURSE 55 

shop morale, raising their level of efficiency, and 
promoting their health, which will result in increased 
output. This last is the true industrial physician 
who really interprets the definition of industrial 
medicine, which states that it is the knowledge of 
medicine, surgery, oral hygiene, sanitation, hygiene, 
safety, economics, and psychology, daily promoted 
and intensively applied to groups of employes for 
the purpose of preventing or shortening the disa- 
bility due to illness and accidents and for the pur- 
pose of adjusting unhealthful working and living 
conditions that surround the industrial job, as well 
as the community life, thereby increasing individual 
efficiency and mass production.'' 

Industrial physicians may be whole or part-time 
men. In a large factory, the chief physician had 
best be on full time, but his assistant physician or 
physicians may well be on part time if the factory is 
in or near a city. 

A part-time industrial physician is a physician or 
surgeon in general practice who gives part of his 
time to industrial practice. A great deal of excel- 
lent work has been done by men of this type who 
have seen and grasped the opportunity offered. 
Without them industry would be greatly handi- 
capped for over 95% of the factories in the United 
States employ less than a thousand workers and 
such factories cannot afford the services of a full- 
time physician. Part-time physicians are also of 
great value as assistants to the chief physicians of 
a large factory. The contact they are constantly 



56 HEALTH SERVICE IN INDUSTRY 

having with private patients and general hospital 
work keeps their professional interest acute and 
forces them to study. Moreover it keeps them in 
tonch with the more advanced forms of the sickness 
they see beginning in the factory dispensary. 

An industrial physician who is in charge of a very 
large staff: of full-time doctors told the author that 
he wished a high turnover among his doctors as the 
continuous handling of simple problems had a ten- 
dency to reduce the initiative and progress of the 
doctor. 

The author feels that his summary in another 
publication covers the ground in a reasonable way. 
In factories employing under a thousand, one part- 
time physician ; in factories of between one and two 
thousand, two part-time physicians; in factories of 
between two and three thousand, the same number 
if one is part time and the other full time. 

Inasmuch as a factory is composed of many de- 
partments each one specializing in some particular 
work, it is necessary that the industrial physician 
have a general knowledge of these departments, and 
a definite comprehension of the detail work of the 
departments with which he comes in intimate con- 
tact. Without this knowledge he is unable to write 
letters and information to the proper department 
nor is he able to co-operate with departments with 
which he is in contact. The doctor has definite 
authority and in all medical matters his decisions 
will be accepted without question, but he must be 
able to show that he is right and produce results in 



INDUSTRIAL PHYSICIAN AND NURSE 57 

order to retain the confidence of man and manage- 
ment. He must initiate requisitions for all hospital 
supplies and equipment, and has it in his power to 
spend large sums of money wisely or foolishly as he 
wishes. The purchasing of medical supplies requires 
careful judgment in order that the maximum value 
may be obtained for each dollar expended. 

He must be able to inspire his nurses and assist- 
ants with confidence, and stimulate them to high 
standards of work, and must be thoroughly believed 
in by the workers. Beginning slowly he must build 
up the dispensary service in just the same way as 
a physician acquires his private practice. The same 
thought, care and sympathy are required by the 
patient whether he obtains them from a private or 
an industrial physician and unless he gets it he will 
go elsewhere. 

The records of the factory dispensary should be 
as carefully guarded as in a doctor's private office 
and the physical condition of a patient should not 
be discussed outside of the dispensary. 

Careful attention to these details has a great 
deal to do with the ultimate success of the depart- 
ment. 

The technique of examination and treatment of 
patients should be carried on as in a general hospital 
service. 

Special emphasis is laid upon these simple details 
for unless they are carried out with great care the 
work of the industrial physician will not obtain max- 
imum results. 



58 HEALTH SERVICE IN INDUSTRY 

One of the greatest privileges of an industrial 
service is the close and long-continued contact with 
a large number of men. The doctor has a wonderful 
opportunity not only for investigation work, but for 
teaching the worker the rudiments of healthful 
living. 

The industrial physician finds that his work nat- 
urally divides itself into medical, surgical and what 
may be termed public health work. Owing to the 
early stage at which many diseases are encountered 
the factory dispensary probably presents one of the 
best fields now open for the study of beginning 
disease and its prevention. As the sanitation as 
well as the health problems of the factory are under 
the doctor 's control, he has it in his power to act as 
a local board of health for the factory and to ob- 
serve accurately the results of his action. 

The doctor will always be measured by his results. 
Factory workers and management are both close 
observers, and unless the best kind of results are 
produced, there is bound to be unfavorable criticism. 
the doctor 's control, he has it in his power to act as 
of time. In the case of accident, days of disability 
will be inexorably charted against him, and every 
infection comes out without possibility of camou- 
flage. Therefore, careful work, good instruction to 
nurses, and a follow-up system are obligatory. He 
will find it necessary to standardize certain forms 
of treatment, both medical and surgical, in order to 
study the efficiency of the form adopted and to save 
time and space. 



INDUSTRIAL PHYSICIAN AND NURSE 59 

The element of time is constantly presenting itself 
to the industrial physician in some new phase. The 
length of time allowed for a physical examination, 
the time it takes for a worker to go to the nearest 
dispensary to have an injury treated and return to 
work, the time taken to make a diagnosis, the time 
taken for taking and filing records, the time lost by 
workers because of sickness and accident, all pre- 
sent themselves before him in what at first appears 
to be a limitless procession. He finds that the 
installation of an X-ray equipment pays because it 
saves the time of the worker which would otherwise 
be spent going to have the picture taken elsewhere, 
and the time of the nurse who would take him. He 
finds that men on piece work will not go far for med- 
ical or surgical care unless sorely in need of it, 
because of the time they lose from work. He won- 
ders at first why time is so important and then real- 
izes that in industry the old adage, "time is money,' ' 
is the reason. As soon as he realizes this he begins 
to see that his whole department and many of its 
results can be measured by a common factor, dollars 
and cents, which can be understood by everyone. 
Many things that he does cannot be so measured, 
but many can, and instead of shrinking from the 
thought of work being so measured, he should be 
glad that there is some definite norm which can be 
applied to measure the results of his department. 

The good industrial physician is constantly study- 
ing not only the results in his department, but new 
methods of diagnosis and treatment. For this rea- 



60 HEALTH SERVICE IN INDUSTRY 

son he should stipulate with the management that 
he be allowed to maintain any outside hospital con- 
nections he may have obtained before going into 
industry, and that he be allowed enough time away 
from his work to visit clinics and attend medical 
meetings. 

In order to obtain good results there must be close 
co-operation between the doctor and the manage- 
ment. The interest and backing of the superintend- 
ent is almost vital to the success of the medical 
department, and the closer the mutual understand- 
ing between doctor and superintendent the more 
effective the work. 

The foreman has been called the "top sergeant' * 
of industry. He represents the company to the 
worker. It is, therefore, of great importance for 
the medical work to have the sympathy and interest 
of the foreman. Close co-operation between fore- 
man and doctor is bound to bring most gratifying 
results and opens an easy contact with the worker. 
The worker to a great degree reflects the attitude 
of the foreman, and enthusiastic support of the med- 
ical department by the foreman makes the problems 
of the doctor much less difficult. 

The industrial physician must be a good team 
worker and be able to co-operate with the heads of 
departments with which he comes in contact. He 
must study the detail of these departments in order 
to so arrange his work that it will not interfere with 
their routine or increase their difficulties. 

The departments in contact with the health de- 



INDUSTRIAL PHYSICIAN AND NURSE 61 

partment have been enumerated in previous chapters 
and some of the points of contact and co-operation 
discussed. 

The Industrial Nurse 

The industrial nurse may fall into one of two posi- 
tions, dispensary nurse or visiting nurse. The first 
of these resembles very closely the position of a 
nurse in a medical or surgical dispensary of a gen- 
eral hospital except that in industry her responsi- 
bilities are usually greater than in general hospital 
work. While under the general supervision of a 
doctor there are long periods when the sub-dispen- 
sary nurse must use her own judgment, and it is this 
faculty of judging whether or not a patient needs 
the doctor's care which determines the nurse's 
ability. 

If we briefly review the method of dispensaries 
which we have laid down as a model it will be noted 
that while the central or main dispensary always 
has a doctor in attendance, the sub-dispensaries are 
visited by a doctor only once daily. At this time the 
nurse is supposed to have ready those cases which 
need a doctor's attention and advice. At any time 
she may send sick or injured men to the central dis- 
pensary to see the doctor there, or may in serious 
cases send for the doctor to come to the sub-dis- 
pensary. 

It is the fifty cases of trivial sickness and accident 
using the sub-dispensary daily which test her judg- 
ment. Does the headache this man complains of 



62 HEALTH SERVICE IN INDUSTRY 

suggest eye strain, and should the doctor see him? 
Is this man's abdominal pain of any significance? 
Does that cough suggest the need of a complete 
chest examination? A good nurse who has had 
experience is very accurate in diagnosis as to 
whether a patient should be seen by a doctor or not. 
She should always play safe and err on the side of 
over-caution. The following general rules may act 
as guides : 

1. Always take the temperature if there is the 
slightest reason to suspect it. 

2. Always take the pulse. 

3. In case of headache think of eyes. If headache 
persists have patient see doctor. 

4. In cases of abdominal pain always take tem- 
perature and pulse. If patient is nauseated or 
has vomited call doctor. 

5. Send to doctor any injury requiring suture or 
splinting. 

6. Send to doctor any patient who has coughed 
a week. 

7. Send to doctor any patient with temperature 
of 100. 

Many other good rules may be added; the outline 
above will serve as a guide. 

There has been some discussion as to the advisa- 
bility of allowing nurses to take this responsibility. 
Theoretically, the industrial nurse may have more 
responsibility than the nurse elsewhere, but unless 
she is given this responsibility, it will be impossible 
to achieve real results in industrial medicine. If a 
doctor is called on to treat every scratch and mild 
coryza occurring in a factory of five thousand, the 
cost will prove prohibitive, and the results will be 



INDUSTRIAL PHYSICIAN AND NURSE 63 

no better than when good nnrses are employed. The 
doctor mnst be always available and must visit each 
snb-dispensary daily, but he need not see every case 
treated. 

The industrial dispensary nurse must be a woman 
of personality and some physical strength, as the 
work is frequently arduous. She must have an 
optimistic temperament, and while being quietly 
sure of herself must co-operate with and depend 
upon the doctor in all important points. 

Her position in a sub-dispensary is one of marked 
responsibility, and she must know just what she can 
do and what should be sent to a doctor. Loyalty to 
her doctors, and team work with them, should be 
the keynote of her work. 

The dispensary nurse has four definite duties : 

1. The treatment of sick and injured workers. 

2. Keeping her dispensary trig and trim. 

3. Making supplies. 

4. Keeping accurate records. 

The treatment of sick and injured must be along 
lines laid out and standardized by the doctor in 
charge. The work consists in first taking and re- 
cording an accurate history of the sickness or acci- 
dent, in the latter case using the technical terms 
occurring in industry. She should get the history in 
the man's own words and know enough about the 
work to realize what these words mean. In order 
that the history may be intelligent, the nurse should 
be shown machines, and be given a clear description 



64 HEALTH SERVICE IN INDUSTRY 

of the parts of the machine and the processes of 
manufacture. The worker who finds his story intel- 
ligently received has confidence in the work of the 
nurse. Moreover the nurse must be able to cull out 
of the story the important facts and construct a con- 
cise history. 

In the case of sickness the nurse must always be 
on the lookout for something underlying the pa- 
tient's story. She should not accept " headache,' ' 
"sick stomach/ ' or "cold" without enough investi- 
gation to be sure she is not in contact with a con- 
dition more serious than the worker realizes. Intel- 
ligent questions, common sense, and the use of the 
thermometer, will prevent mistakes. As the dis- 
pensary is visited daily by a doctor it is very easy 
for her to administer a simple remedy and instruct 
the patient to return at the doctor's visiting hour 
if she has any question as to the case. The drugs 
placed in the nurse's hands are always of the sim- 
plest type. They should not exceed ten in number 
and should include neither opiates nor poisons. 

In order that there should be no temptation to 
elaborate surgical treatment the instruments pro- 
vided at the sub-dispensary need be no more than a 
pair of bandage scissors, two pairs of small surgical 
scissors, two pairs of forceps, and two haemostats. 
The maintenance of a neat and clean dispensary is 
obligatory. The effect of neatness and cleanliness 
upon the patient cannot be overemphasized, and the 
nurse should take pride in the looks and equipment 
of the dispensary in her charge. 



INDUSTRIAL PHYSICIAN AND NURSE 65 

A great deal of unnecessary expense can be elim- 
inated if the nurses during their spare moments 
make supplies. Gauze bought in large quantity 
through the purchasing department should be made 
up into appropriate sized sponges or other forms of 
dressing. Adhesive plaster should always be pur- 
chased in rolls five yards long by twelve inches wide, 
and sheet wadding in bulk. 

Besides folding gauze, rolling sheet wadding, and 
cotton tipping applicators, the nurse should cut ad- 
hesive plaster in appropriate widths and attach it 
to a bread board, by far the easiest method of han- 
dling this rather tricky material. All sterilization 
should be done at the central dispensary by the 
steam fractional method unless the expense of an 
autoclave is justifiable. 

The nurse in charge of the central dispensary 
should be in charge of supplies, requisitioning them 
from the general factory stores, and distributing 
them to the nurses for preparation. She should be 
personally responsible for sterilization under the 
instruction and supervision of the chief physician. 

The keeping of accurate records of work done is 
one of the most important functions of the dis- 
pensary nurse. Not only must she take an accurate 
and brief history of each case, but she must enter a 
simple diagnosis and treatment on the initial report. 
All subsequent dressings and sickness must be 
briefly but accurately recorded and the follow-up 
sheet previously spoken of must be kept with minute 
care. A great deal of the value of the records 



66 HEALTH SERVICE IN INDUSTRY 

depends upon the accuracy and conscience of the 
dispensary nurse, and without her interest and 
co-operation records will be of little value. 

The work of the visiting nurse is quite different. 
It is her peculiar function to act as a connecting 
link between the health department and the worker 
in his home. She also represents the company to 
the employe's family, and by her tact and kindness 
has it in her power to create good feeling for what 
is sometimes considered a soulless corporation. In 
the unique position she holds it is most important 
that she be a woman of tact, sympathy and judg- 
ment, as well as having a sound training as a nurse. 

While the visiting nurse in very large factories 
often does definite nursing at the employe's home, 
in the majority of cases she acts more in the capacity 
of a social worker, investigating the needs of the 
employe or his family, and advising him how to 
meet the conditions under which he is suffering. 
Actual nursing is usually turned over by her to the 
local district nursing society. She must, therefore, 
be prepared to meet many social emergencies, and 
untangle family troubles, for in connection with the 
worker's sickness are a multitude of perplexing 
problems which must be solved. 

The visiting nurse usually receives her list either 
from the employment department or the health de- 
partment of the factory. The employment depart- 
ment sends her the names and addresses of those 
workers whom the tracer finds to be out because 
of sickness, accident, or sickness in the family. 



THE PHYSICAL EXAMINATION 67 

The health department sends her the names and 
addresses of those it wishes visited for special rea- 
sons or to be brought to the dispensary for dressings. 

The scope of the visiting nurse 's work is so broad 
that it can only be outlined. It is limited solely by 
the time she can give to each case. Thus she may 
find the employe sick without a doctor, and his wife 
so harried by household affairs that she is unable to 
give him anything but scanty attention. It is then the 
nurse's duty to make the patient comfortable, take 
his temperature, and advise him to call in a doctor. 
If he knows of no doctor, being a stranger, she must 
be able to suggest some one who is competent, but 
whose charge will be commensurate with the pa- 
tient's pocketbook. Perhaps it will seem better that 
the patient go to the hospital or the doctor in charge 
wishes the patient to go. The nurse then makes 
arrangements with the hospital and, perhaps, trans- 
ports the patient there in her car. 

If it is found that the wife is sick and the husband 
unable to work because there is no one to care for 
the children, she must arrange to have them taken 
care of by neighbors or some association. In cases 
of death the nurse has been frequently obliged to 
arrange for the funeral because of sickness among 
other members of the family. 

Most visiting nurses have an emergency fund 
upon which they may draw in order to purchase coal 
or food for destitute families and tide them over a 
crisis. The visiting nurse also has a list of cases 
whom she visits regularly, bringing a word of 



68 HEALTH SERVICE IN INDUSTRY 

encouragement and keeping them in contact with 
their old associations. Such cases are those who 
have long-continued sickness, accidents of unusual 
severity and those who are in the hospital for oper- 
ative or other treatment. Her function is to help, 
brighten and encourage, and the amount of real good 
she does for both worker and company has never 
been sufficiently recognized and appreciated. 



CHAPTER VI 

THE PHYSICAL EXAMINATION 

The keystone of medical supervision is the phys- 
ical examination. 

"The physical examination is the means whereby 
physicians acquire the information they deem es- 
sential to the procurement and maintenance of 
healthy, physically competent working forces. It 
is consequently the basis of medical knowledge in 
industry and is fundamental to the successful 
practice of industrial medicine." (Selby,^ Scope of 
Physical Examination in Industry. Proc. National 
Safety Council, 1919.) 

It represents the first contact of the employe with 
the health department. It has for its object the 
determination of the employe's physical fitness for 
the work for which he has been selected by the em- 
ployment department, and the recording of his orig- 
inal condition for the private records of the health 
department. 

The physical examination should be given before 
the employe is actually hired as part of the prelim- 
inary investigation. The examination is conducted 
in private by the physician in person, though the 
weight, height, eye and ear tests may be made by a 
nurse or trained layman. The method of procedure 
is as follows : 

69 



70 HEALTH SERVICE IN INDUSTRY 

The applicant, having removed his shoes, stock- 
ings and all his clothes, in a booth, wraps himself in 
a blanket and steps into the examining room. He is 
immediately weighed and his height taken. 

The eye examination follows. This consists in 
most factories in the simple distance test with the 
Snellen chart. In some factories where special work 
requires acute vision, a more complete examination 
is made. The card test having been made, the exam- 
ining physician rapidly examines the motion of the 
eye, the color of the sclera, and the reaction of the 
pupil. He also notes the condition of the conjunc- 
tiva. All this takes only a few seconds. 

The ears are next examined. This may be done 
as in the Army by asking the applicant to repeat a 
whispered number or word, or a more rapid test 
may be made with the standard Ingersoll watch. If 
deafness is noted the auditory canal should be rap- 
idly inspected for discharge or impacted cerumen. 

The examination of the nose is for obstruction or 
defects. These can be rapidly discovered by press- 
ing with the finger on one nostril and telling the 
patient to breathe deeply through the other. If the 
breathing appears obstructed on either side a more 
careful examination with a speculum should be 
made. The patient is now told to open his mouth 
and with the aid of a wooden throat stick, the con- 
dition of the teeth, tongue, tonsils and pharynx 
noted. The lips should be examined on the buccal 
side for possible mucous patches. 

It is not considered necessary to chart decayed and 



THE PHYSICAL EXAMINATION 71 

lost teeth, especially if a dentist is on the health 
department staff. 

The findings of the examination, as noted thus 
far, are briefly dictated to a clerk who enters them 
on the patient's physical examination card. 

The neck is next inspected and then rapidly pal- 
pated for enlarged glands or tnmors. The patient 
is told to swallow and the size and shape of the 
thyroid noted. 

The examination of the. chest is carried out as in 
general or hospital practice. Particular care is 
taken in the examination of the size of the heart, 
and the condition of the apices of the lung. 

Speed in examination is essential so that, though 
the examination should omit nothing, it must be 
concentrated on the points of industrial rather than 
medical importance. By this we mean that we are 
interested in determining in the shortest possible 
time the defects which would make it necessary for 
the worker to be placed in a department other than 
that already selected for him by the employment 
department. Thus the examiner is most anxious to 
determine the functional power of the heart and 
lungs. 

A quick method is to run over the apices of the 
lobes of both lungs with a stethoscope, telling the 
patient to breathe in, breathe out and then cough. 
This expulsive cough at the end of expiration is of 
great service in bringing out rales. In hearts which 
show enlargement, irregularity, or produce mur- 
murs, a quick test of function is to have the patient 



72 HEALTH SERVICE IN INDUSTRY 

hop twenty -five or fifty times on one foot. Rapidity 
of respiration, breathlessness and irregularity of 
pulse should be noted and, if marked, indicate a 
myocardium inefficient for hard work. Further 
tests for the heart will be noted later. The hopping 
test is also of value in lung cases, as breathlessness 
is early evidence of tuberculosis. 

After rapidly reviewing the condition of the heart 
and lungs and dictating any abnormal findings, the 
patient is examined abdominally. The examination 
is made with the patient recumbent, and is to deter- 
mine the presence of inflammatory conditions or new 
growths. The patient is then told to sit on the edge 
of the table and tested for the condition of his knee 
jerks. He then resumes his upright position in 
front of the examiner. The umbilical, inguinal and 
femoral rings are rapidly but carefully examined 
for hernia. In examining the inguinal ring the 
patient is told to stand on his toes. The examiner 
invaginates the scrotal skin and places the tip of 
the index finger in the external ring, bidding the 
patient cough. This enables him to appreciate not 
only the descent of a sac, but the condition of the 
external ring and tension of the surrounding 
muscles. Following the examination of the inguinal 
region in which, of course, any enlarged glands or 
other abnormalities are noted, the external genitals 
are rapidly reviewed for venereal or other disease. 

The examination is now complete except for the 
extremities, skin and joints. The condition of the 
skin and extremities can be noted at a glance, but 



THE PHYSICAL EXAMINATION 73 

the joints should be tested out carefully. There 
are a number of methods equally satisfactory. The 
one here described is rapid, efficient and has been 
used for some time in a large factory. 

1. Patient stands facing examiner, forearms flexed 
on arms, hands in supination. 

2. Patient spreads fingers apart and brings them 
together, closes fists, opens fists, apposes tips 
of thumbs to little fingers, pronates and again 
supinates. 

3. Flex forearms acutely until fingers touch shoul- 
ders. Raise elbows anteriorily as high as pos- 
sible. 

4. Abduct both arms in this position and rotate 
shoulders. 

5. Raise hands straight up above head as high 
as possible. 

6. Bend over touching ground. 

7. Resume erect position. 

8. Squat on heels and rise to original position. 

9. Abduct first one leg and then the other. 
10. Rotate head from side to side. 

If these motions are gone through rapidly, they 
can be accomplished in about three minutes, and 
every important joint in the body will have been 
tested. It has been found that defective joints are 
more apt to cause trouble than other apparently 
more serious disorders in other parts of the body. 

There is considerable difference between the 
examination of patients in a hospital and the exami- 
nation of apparently normal men for work. In the 
former one knows that some pathological condition 
exists severe enough to require hospital care. In 
the latter the patient is applying for work as a nor- 



74 HEALTH SERVICE IN INDUSTRY 

mal man, and the examination is to determine as 
quickly as possible whether he is physically fitted 
for the work at which he will be placed. In gen- 
eral hospital work, time is of no particular impor- 
tance. In industrial work it is of vital importance. 
The employment department is anxious to fill its 
requisitions at the earliest moment, employes object 
to waiting, congestion must be avoided at all costs. 
The usual time allotted to the physical examination 
is, on the average, five to six minutes. It is only 
by experience and system that an adequate exami- 
nation can be made in this limited time. The physi- 
cian must, therefore, concentrate on what may be 
called the industrial physical defects, expecting to 
discover those which are less serious at subsequent 
examinations when the employe is under medical 
supervision. The vast majority of applicants are 
standard men. They have numerous slight defects 
but none of enough severity to require special place- 
ment or rejection. A second group, much smaller, 
but still from 8 to 10 per cent, of all applicants are 
sub-standard and need placing. A third very small 
group from 2 per cent to 5 per cent cannot be placed 
anywhere in the factory without danger to them- 
selves, others, or property. The object of the physi- 
cal examination is to determine as quickly as pos- 
sible those who are standard; sub-standard men 
require a much more careful examination to deter- 
mine the extent of their defects, and it is usual to 
complete the examination of these men after the 
early morning hiring rush is over. 



THE PHYSICAL EXAMINATION 75 

Sub-standard workmen may be divided into three 
classes: those who are sub-standard mentally, but 
standard physically; those who are sub-standard 
physically, but standard mentally; those who are 
sub-standard both mentally and physically. It is 
evident that the man who is mentally sub-standard 
but physically standard can usually be placed at 
heavy work requiring no particular ability. There 
are many places of this type open in every indus- 
try. When the mental condition is standard but 
the physical condition is sub-standard the problem 
of proper placement must be solved. When both 
mental and physical conditions are sub-standard, 
the applicant is usually unfitted to work in any 
department of the factory, and it is advisable for 
his own good and for the good of industry that he 
turn his work into other fields. 

The method of classifying these groups of men 
has already been considered and the method of their 
placement briefly discussed in Chapter Three. In 
considering sub-standard workmen alone, those who 
are sub-standard mentally but standard physically 
can usually be safely classified as B. When the men- 
tal condition is standard but the physical condition 
sub-standard, the applicant is classified as C, and re- 
quires placement. When both mental and physical 
conditions are sub-standard the applicant is classi- 
fied as D. \ 

Physically sub-standard men usually fall into one 
of the following classifications : Cardiac, nephritic, 
pulmonary, hernial, syphilitic, special and general. 



76 HEALTH SERVICE IN INDUSTRY 

Cardiac. — The number of cardiac cases which are 
unable to work are relatively few. Workers with 
defective hearts, even though the heart upon exami- 
nation shows marked murmurs and even irregulari- 
ties, are able to stand moderate work for a number 
of years before showing signs of disturbed com- 
pensation. The industrial physician should deter- 
mine as much as possible with the stethoscope, but 
should pay the closest attention to the condition 
of the myocardium. Though this is an extremely 
difficult thing to determine in a short examination, 
a functional test in suspicious cases will usually 
give a lead in the right direction. The simplest test 
is that of having the applicant hop fifty times on 
one foot, examining the heart before and after exer- 
cise, and noting particularly the effect upon the 
rapidity and regularity of the pulse, and the time 
for it to fall to normal. At the same time the reac- 
tion of the respiration to this moderately violent 
exercise should be closely noted. A patient who 
becomes breathless, or shows any signs of abnormal 
breathing after this exercise as compared with the 
normal man is one who should be studied with great 
care and who should not be assigned to work which 
will throw any strain upon the heart. This point 
of breathlessness has been emphasized by Lewis in 
his recent monograph on the Soldier's Heart and 
the Effort Syndrome. The exercise also brings to 
the examiner's attention any cases of that mysteri- 
ous condition known in the army as neurocircu- 
latory asthenia, the familiar N. C. A. Such cases 



THE PHYSICAL EXAMINATION 77 

are rare in industry, but if met should be imme- 
diately isolated as they have no business in the 
hard work of the average factory. Dr. William E. 
Robertson of Philadelphia in a paper delivered in 
Harrisburg at the annual Pennsylvania Safety Con- 
gress, 1920, reviewed the question of the cardiac in 
industry and outlined the best method of examining 
a heart from an industrial viewpoint. Some of his 
points are as follows : 

"Of first importance are the position and quality 
of the apical impulse of the heart. Normally in 
the fifth interspace in the mid-clavicular line, dis- 
placement means hypertrophy with or without 
endocarditis, dilation, or both of these, adhesions 
or mechanical displacement by effusion or new 
growths. . . . Having marked the outline of the 
right and left heart, make friction over the epi- 
gastric area for a minute, then percuss the heart 
area again. If the area was large and has been 
reduced, we are dealing with simple hypertrophy. 
If the area reduces only in part, we have both 
hypertrophy and dilation, or dilation alone when 
the area reduces to the normal. Within two min- 
utes the heart area returns to the original out- 
line. . . ." 

"Normally, after moderate exercise, such as hop- 
ping 100 times on one foot, the rate will increase 
10 to 30 beats above the previous rate, but within 
two minutes will return to the normal. In propor- 
tion to the degree of deterioration of the heart 
muscle, the rate will increase and the greater the 
increase, the slower the return to normal. When to 
this increase in rate is added dyspnea, with a sense 
of substernal pressure, the muscle involvement is 
very definite. In such instances by auscultation 
the muscle quality of the heart sounds will be 
found weakened, arrhythmia may be induced, and 



78 HEALTH SERVICE IN INDUSTRY 

not seldom a relative mitral systolic murmur. In 
the over-acting heart an induced mitral murmur 
may simulate mitral stenosis. 

"Morison has shown that inhalations of amyl 
nitrite will accentuate the organic lesion of the 
valve. Whenever in doubt as to the possibility of 
mitral stenosis in any case, this is an excellent di- 
agnostic aid. When simple tachycardia is present, 
Benjamin and Brooks have shown that merely 
bending the head forward at an angle of 45° will 
promptly retard the heart rate. Fliessinger has 
reported similar results with respect to respira- 
tory effort in paroxysmal tachycardia. Sustained 
respiration, deep inspiration and prolonged expira- 
tion will often slow the heart rate." 

Nephritic. — Nephritic workmen can be most 
rapidly discovered by blood pressure determinations. 
A good general rule is to make a blood pressure 
determination on all applicants of forty years or 
over, and an urinalysis on all those showing a pres- 
sure of 140 systolic, 90 diastolic or over. Nephritic 
cases cannot stand the extremes of heat and cold 
which exist in many departments, nor have they the 
resiliency against hard work the normal individual 
has at the same age. The majority of these cases 
have more or less myocardial degeneration and the 
cardiac condition should always be investigated. A 
great deal can be done for the nephritic in the way 
of advice and diet. If he is hired he should be kept 
under medical supervision and re-examined at suit- 
able intervals. 

Pulmonary. — The most frequent pulmonary con- 
dition found among sub-standard men is a latent 
tuberculosis. This may be discovered by a combina- 



THE PHYSICAL EXAMINATION 79 

tion of the patient's general build, physical signs 
in the chest and breathlessness on exertion. Again 
we see the advantage of putting the patient through 
the fifty hops on one foot, and by this simple method 
we are able to judge two conditions, cardiac and 
pulmonary. Applicants with latent tuberculosis 
can be employed in numerous departments in the 
factory, but should certainly not be put in a dusty, 
dark or humid workroom. If kept in a bright, dry 
workroom they are able to do excellent work with- 
out breaking down. 

Ee-examination of all workers with latent tuber- 
culosis is essential. The examination should be 
made at least twice a year and the worker instructed 
to report for additional examination if he begins 
to cough, lose weight, suffers from dyspnoea, or 
feels unusually tired in the afternoon. Sputum 
examinations and the taking of temperature in the 
afternoon should be repeated several times in sus- 
picious cases. 

An X-ray is a great help in diagnosing difficult 
cases. Excellent chest pictures can be obtained with 
small machines such as the U. S. Army Bedside 
Unit.* 

Hernia. — One of the most perplexing conditions 
which the industrial physician encounters is hernia. 
A general rule has been to be extremely careful 
about admitting men with hernias into industry. 
This is partly on account of the compensation risk 
in cases of strangulation, partly on account of the 

*May be purchased from Waite & Bartlett, 252 West 29th 
Street, New York. $650.00. (1920.) 



80 HEALTH SERVICE IN INDUSTRY 

necessity of repairing the hernia if the man com- 
plains of pain after lifting, even if there is no 
increase in the size of the hernia, and partly because 
where there is a hernia on one side there is usually 
a tendency for a hernia to appear on the other side.* 
Compulsory use of trusses cannot be enforced, so 
that in the majority of factories there has been a 
strong feeling against the man who has a hernia. 

In many factories, however, men with well-marked 
hernias have been employed and work for years 
without trouble. In one factory where a careful 
record has been kept for nine years, but one case 
of strangulation has occurred, and this took place 
while the man was not at work. The great major- 
ity of these old hernia cases appear to be a fairly 
safe risk provided they continue doing work of the 
same type, and are not put on a job which is much 
heavier. The real hernia risk appears to be among 
southern Europeans, and among men who having 
done only moderately heavy work are suddenly put 
on heavy work. It is very difficult to determine who 
will develop a hernia, but it is safe to say that all 
southern Europeans who have previously done light 
work are very liable to develop a hernia if put on a 
heavy job. A worker with weak rings and a slight 
bulge along the inguinal canal on cough is a man 
who should not be put at heavy lifting. 

Syphilitic. — A diagnosis of tertiary syphilis is 
very difficult in the short examination which is given 
the average applicant. However, if the factory hos- 



*Moorehead states that 80% of his operated cases show oblique 
hernia on both sides. 



THE PHYSICAL EXAMINATION 81 

pital is used as it should be, cases are constantly 
appearing in wliich there is enough to arouse the 
doctor's suspicion and lead him to take a Wasser- 
mann. These cases, if the Wassermann is positive, 
should immediately have salvarsan, following which 
the type of work at which the patients are placed 
should be carefully investigated. 

Special. — There are naturally a number of con- 
ditions wliich do not fall in any of the above groups, 
but which, nevertheless, require careful placing. 
These are too numerous even to mention, but will 
readily occur to any industrial physician. A typical 
example would be varicose ulcers of the leg. These 
cases may be placed at moderately light work, and 
with protection do extremely well, the ulcer healing 
up rapidly under daily cleansing at the hospital and 
proper support. Flatfoot is another condition in 
which a combination of placing and support gives 
excellent results. Our own experience goes to show 
that flatfoot is more a theoretical than a real detri- 
ment to good work. 

General. — There are always a number of cases 
which present a combination of conditions which 
can only be cited as general. Many of these patients 
fall under class D group, and really have no busi- 
ness to work anywhere in the factory. Others may 
be placed and a moderate amount of good work 
obtained from them. Proper placement does not 
finish the doctor's responsibility. These sub-stand- 
ard men must be examined from time to time to see 
that their defects are not increasing and that the 



82 HEALTH SERVICE IN INDUSTRY 

placing has been proper. Such an examination 
should be made as a routine twice a year; and at 
each examination a record should be made showing 
the patient's condition. The doctor should take 
enough time to discuss with the patient his find- 
ings, and to give advice as to how the patient may 
maintain himself in good condition. If the patient 
has confidence in the doctor and medical service, and 
the symptoms which mean beginning trouble have 
been thoroughly explained to him, he will present 
himself for examination long before there are any 
real signs of breaking down. 



CHAPTEE VII 

ACCIDENTS AND THEIR TREATMENT 

Accidents occurring in a factory may be classified 
as trivial, moderately severe and severe. Legally, 
they are classified as trivial, and lost time accidents. 

Trivial accidents are those in which the worker 
is able to continue work immediately after treat- 
ment and which require but two or three dressings. 
They may be cared for by a nurse or trained lay- 
man. 

Moderately severe accidents are those which re- 
quire a doctor's care. The patient may or may not 
lose time. 

Severe accidents are those which require a doc- 
tor, and usually general hospital care. 

The treatment of accidents in a factory begins 
with the first aid treatment and is not completed 
until the worker is back at his original work or at 
other work approximating it as closely as possible 
in earning capacity. 

First aid may be carried on at first aid stations 
scattered through the factory, or at factory sub- 
dispensaries. 

The first aid station with its equipment has 
already been described in Chapter IV. As there 
stated, the equipment is usually in the hands of a 

83 



84 HEALTH SERVICE IN INDUSTRY 

trained layman, either a foreman or sub-foreman. 
The treatment administered should be strictly first 
aid, that is, just enough to control the emergency 
features of the case and to prevent infection. 

By far the largest number of accidents are trivial 
injuries, and these in turn are most frequently 
lacerated wounds of the fingers. 

Every injury in which the skin is broken repre- 
sents a potential infection, and the prevention of 
infection is one of the most important services ren- 
dered by the factory medical staff. The shorter 
the period elapsing between injury and treatment 
the more effective the result. 

Mock has shown the remarkable results obtained 
by the early use of Iodine, and the Benzene-Iodine 
treatment of wounds has now become almost stand- 
ard in industry. The results have been most gratify- 
ing. Hundreds of consecutive cases have been 
treated without a single case of infection, and when 
the working conditions and habits of the average 
factory worker are considered, the statistics are 
surprising. 

In one company employing about 900 machinists 
there was but one accident in which time was lost 
from infection out of 4,869 accidents. The period 
covered was 23 months. The technique consisted 
in thorough cleansing of wounds and skin with 
commercial gasoline followed by full strength Tr. 
Iodine U.S.P. Mock bases the prevention of infec- 
tions upon three points : 



ACCIDENTS AND THEIR TREATMENT 85 

a. "Immediate application of an antiseptic to an 
open wound. 

b. The earliest possible treatment of the wound 
by a qualified physician. 

c. Protection of the wound by sterile dressings; 

regular and uninterrupted care until healed." 

He goes on to say, "from a careful investigation 
of the kind of antiseptic used in accident surgery- 
it is safe to say that at least 80 per cent of the 
surgeons use some form of tincture of iodine." It 
will be noted that in Chapter IV in the description 
of a first aid jar that benzene is not included. This 
is because the treatment is to be given by a layman 
and simple flushing with iodine is safer than allow- 
ing a thorough cleansing with benzene and iodine. 

Where the first treatment is carried out by a 
trained nurse or doctor, the wound should always 
be thoroughly cleansed with benzene or gasoline be- 
fore iodine is applied. Water should never be used 
prior to the gasoline-iodine. If the patient has been 
working in water the wound should be flushed with 
alcohol and ether before applying the iodine. 

Whenever possible, the most satisfactory place to 
give first aid is the sub-dispensary where everything 
is at hand for proper treatment and where a trained 
nurse does the work. 

The first treatment of the more common injuries 
can be readily standardized and equipment be at 
hand and ready for the immediate treatment of 
these cases. Such standardized treatment would 
be as follows: 



HEALTH SERVICE IN INDUSTRY 

Lacerated Incised and Abrased Wounds 

1. Cleanse part freely with gasoline, using ster- 
ile gauze. 

2. Wipe out wound thoroughly with cotton ap- 
plicator dipped in gasoline. 

3. Paint wound thoroughly with iodine, using a 
cotton swab applicator, or spray iodine into 
and around wound. 

4. Apply sterile gauze compress. 

5. Bandage. 

6. Reinforce bandage with adhesive plaster 
strips. 

Sprains 

1. Shave. 

2. Bandage. 

3. Transport to doctor. 
Burns 

1. Cleanse gently with saturated solution of 
soda bicarb. 

2. Apply 3% soda bicarb, ointment or in mild 
cases powder with Compound Stearate of 
Zinc. 

3. Apply dry sterile dressing held in place by 
a not too snug bandage. 

Strains (back) 

1. Strap using straps 3" wide. 

2. Bake with electric heater. 
Fractures 

1. Put injured part at rest by immediate im- 
mobilization in appropriate splint. 

2. Summon doctor. 
Haemorrhage 

1. Paint rapidly with iodine. 

2. Apply mass of 3 in. x 3 in. sterile gauze com- 
press held snug with bandage. 

3. Splint. 

4. Apply tourniquet only if absolutely neces- 
sary. 

5. Summon doctor. 



ACCIDENTS AND THEIR TREATMENT 87 

Eye Injuries 

1. Flood eye with 4% Boric Acid solution. 

2. Wipe out loose particles with sterile cotton 
swab on applicator. 

3. In case injury is severe or if foreign body 
is imbedded in cornea, drop castor oil freely 
into eye, apply sterile gauze, bandage loosely 
and send to physician. 

Such standardized treatment when used by each 
hospital worker in exactly the same way inspires 
the confidence of the worker and rapidly proves to 
the medical staff the value of the treatment. Any 
method which does not give good results is imme- 
diately apparent and can be changed for a better. 

While trivial cases can be safely treated by a 
specially trained nurse under the supervision of 
one of the medical staff, all cases of moderately 
severe injury should be seen by a doctor at once. 
The efficiency of the first treatment and accuracy 
of diagnosis plays a most important part in the 
rapidity of recovery and the functional end result 
obtained. As an aid to diagnosis and treatment the 
value of a small X-ray equipment cannot be over- 
estimated. All injuries to the extremities of a twist- 
ing or crushing nature should be X-rayed as should 
all cases of sprain and strain. The number of slight 
fractures which occur as the result of industrial 
accident is striking. If treated by immediate im- 
mobilization, rest and early mobilization, they do 
well. If treated as minor injuries they produce 
prolonged disability. It is always advisable to X-ray 
the spine and sacro-iliac regions after alleged back 
strains. The author has found that the great major- 



88 HEALTH SERVICE IN INDUSTRY 

ity of incapacitating back strains are due to either 
a true sacro-iliac sprain or to an unsuspected chronic 
arthritis of the spine. When there is an underly- 
ing pathological condition, a very slight strain of 
the back is followed by marked spasticity of the 
back muscles and prolonged disability. 

In cases of fractures of the fingers, proper reduc- 
tion and retention are imperative if function is to 
be required. Fracture of the proximal phalanx, 
especially if comminuted, is the most difficult finger 
fracture to treat and the results are usually most 
disappointing even when good reduction is obtained. 
The industrial surgeon should study this type of 
fracture with great care for if a stifi finger results, 
as is frequently the case, amputation may be neces- 
sary. 

Moderately severe crushing and lacerating in- 
juries require a general anaesthetic and a surgical 
debridement similar to that used on war wounds. 
We have found that the French method of flushing 
the wound with ether following debridement, 
minutely careful haemostasis, approximation of 
deep structures in order that dead space be elimi- 
nated, and the free use of dichloramin T will pro- 
duce a sterile wound in almost every case. 

Puncture wounds of the foot caused by nails pro- 
truding from boards is a fairly common accident 
which should always be considered as moderately 
severe. Thorough treatment of the wound by in- 
jection of gasoline and iodine is usually successful 
in preventing infection. 



ACCIDENTS AND THEIR TREATMENT 89 

The above are types of moderately severe injury 
commonly met in industry. In order to treat these 
and similar injuries properly ,^ the surgeon should 
have an assistant capable of giving a general anaes- 
thetic, unless he sends cases of this type to a gen- 
eral hospital for treatment. 

Severe accidents require the immediate attention 
of a doctor. First aid should be given the patient 
at the point where the accident occurred, but this 
should be of the simplest type. Transportation 
should be done only under the doctor's direct super- 
vision. 

In each sub-dispensary or at each first aid sta- 
tion, there should be a stretcher, with blankets, a 
first aid outfit packed for immediate use and a 
Thomas hip splint. These three should be brought 
to the patient as quickly as possible. 

The patient having been placed on the stretcher 
is transported to the central dispensary where fur- 
ther semi-definitive treatment is carried out prior 
to the patient's final transportation to a general 
hospital. 

The arrangement of personnel for handling acci- 
dents may well be as follows : 

At each sub-dispensary one or two nurses depend- 
ing upon the activity and size of the zone covered. 

Each sub-dispensary is visited daily by a doctor 
who makes an investigation of all trivial injuries 
which are not doing well and of all moderately 
severe injuries under treatment. At the central dis- 
pensary there is always a doctor and at least one 



90 



HEALTH SERVICE IN INDUSTRY 






Report Sent 
immediately 
to S. E. Dep't 
for Recording 



Report Sent Immediately 

to S.E.Dept.for 
Records and Reporting 

to 
State and Insurance Co. 



Fig. 6. (a) Course of a Patient Having a Trivial Accident 
(b) Course of a Patient Having a Moderately Severe Accident 



ACCIDENTS AND THEIR TREATMENT 



91 



At Work 



Employment 
Department 



Finds Work 
Which Patient 
.Can Perform . 



Nearest 
Branch Hospital 

Immediate 
Treatment 



If Unable to Resume 
Old Work at Once 



Safety 
Eno/.r'gDep't 



Compensation 
Payments 



Main 
Factory Hospital 

Intermediate 
Treatment 



Main 
Factory Hospita l 

Observations 
Dressings 
Release 



Home 



Visiting Nurse 
Calls 




Report set 
immediately 
to S. E.for 

Recording and 
Repairing to 

I nd. Ace. Board 
and Ins. Co. 



Fig. 6. (c) Course of a Patient Having a Severe Accident 
(Courtesy of Oxford Loose Leaf Medicine) 



92 HEALTH SERVICE IN INDUSTRY 

nurse in constant attendance. All moderately severe 
injuries are treated there as well as those cases of 
severe injury which have been discharged from the 
general hospital. 
To recapitulate: 

1. All cases of slight injury are treated at first 
aid stations or sub-dispensaries and re-treated 
at sub-dispensaries by a trained nurse. 

2. All cases of moderately severe injuries are 
treated at first aid stations or sub-dispensaries 
for first aid, and are transferred at once to 
central dispensary for definitive treatment by 
doctor. 

3. All cases of severe injury are treated by doctor 
who supervises transportation. Semi-definitive 
treatment is given at central dispensary and 
final or definitive treatment is given at a gen- 
eral hospital. 

Every case of injury establishes a contact with 
the Safety Engineering Department and whatever 
department reports accidents under the Workmen's 
Compensation Act. In many cases this is a branch 
of the Safety Engineering Department. 

This contact consists of : 

1. An investigation of the accident by the Safety 
Engineer to determine its cause and possible 
future prevention. 

2. A report of the accident 

(a) to the proper state authority 

(b) to the insurance company. 

3. Recording the accident from the point of view 
of time lost and compensation due. 

4. Arrangement with employment manager for 
placement of injured worker, after consultation 
with doctor as to type of work the injured em- 
ploye should do when able to return to work. 



ACCIDENTS AND THEIR TREATMENT 93 

Every case of severe injury also establishes a 
contact with the visiting nurse's service. This con- 
tact consists of : 

1. A report of the case to the visiting nurse with 
a request to visit the injured man at his home 
or at the hospital. 

2. A series of reports by the nurse to doctor of 
the progress of the case. This is entered on the 
worker's medical record. 

3. A report to the doctor when the patient is dis- 
charged from the general hospital in order that 
the doctor may visit the case if necessary. 

4. The visiting nurse frequently brings moderately 
severe injuries to the factory dispensary for 
dressings and acts as a transporting agent. 

At no time should the medical staff lose touch 
with the injured worker. His exact condition must 
be known and recorded from the time of the injury 
until he returns to work, and then any existing dis- 
ability must be clearly stated. 

The cycle of a severe type of accident is graphi- 
cally shown in the accompanying cut. (Fig. 6.) 

The Workmen's Compensation Act now in force 
in the majority of states makes accuracy of diag- 
nosis and a close following of the case obligatory. 
The importance of a careful history and thorough 
examination is well shown in the following case of 
supposed back strain: 

J-H, 44 years old, married, machinist. Past 
History: Apparently normal man when hired 
Feb. 19, 1918. About two years ago severe pyor- 
rhea for which all teeth removed. About a year 
ago, noticed he was losing weight and did not feel 
quite well. At the same time he noticed he was 
drinking large quantities of water and urinating 



94 HEALTH SERVICE IN INDUSTRY 

freely. He paid no attention to this and did not 
consult shop hospital or physician. 

Present History: On November 6, 1920, at 
11:30 a. m., while lifting welding tanks, felt a 
catch in his left back. On November 11 at 4 p. m., 
he came to the shop hospital complaining of pain 
in his back. He was strapped and baked. He was 
treated every other day until November 17, 1920, 
when he was examined by a doctor whose examina- 
tion report is as follows: 

"Patient stands with slight list to left, low dor- 
sal and upper lumbar scoliosis. Motion: flexion 
forward, restricted to about one half, to the left 
about one third, to the right considerably less than 
one fourth. Diagnosis : Sacroiliac strain with pos- 
sibly underlying infectious arthritis." 

Patient sent next day to Memorial Hospital for 
X-ray of back and application of plaster cast. 
X-ray was negative. During routine examination 
urine was found to be four plus for sugar. 

Diagnosis: Severe diabetes. Transferred medi- 
cal. Patient put on anti-diabetic diet and further 
examinations made. Found to be a total diabetic 
with tendency to acidosis. Acetone and diacetic 
acid in urine. 

Examination of abdomen at this time disclosed a 
feeling of resistance in left lumbar region. Patient 
since admission ran a low irregular temperature 
varying between 98 and 100, and a slightly in- 
creased pulse averaging 90. 

Blood count showed 24,800 white cells. Differen- 
tial 90% polys. 

On November 29, the mass in the lumbar region 
had become pronounced extending from under ribs 
to anterior-posterior spine. It was slightly tender 
on pressure and pressure upon the mass elicited 
pain down left sciatic nerve. The pain is the same 
as that complained of since the back strain. The 
mass feels tense, seems to be present in the lumbar 
region posteriorily and suggests fluctuation. 



ACCIDENTS AND THEIR TREATMENT 95 

Diagnosis: Perinephritic abscess in left kidney 
region possibly involving pancreas. 

Operation of incision and drainage under local 
anaesthetic advised but refused by patient who left 
the hospital at own risk. 

December 6. Accepted operation. Incision re- 
vealed abscess of left kidney and perinephritic 
region with about two quarts of pus. 

December 12. Patient died in diabetic coma. 

Comment: There seems to be no question but 
that this patient had diabetes becoming total, fol- 
lowed by secondary abscess of the kidney which in 
breaking down caused a perinephritic abscess. The 
history of back strain was false and the symptoms 
simulating back strain were due to the condition of 
the kidney. 

The error made in the factory medical depart- 
ment was in not eliciting a complete history before 
sending the case to the general hospital. A well- 
taken history would have suggested diabetes at once, 
and the urine would have been examined. The close 
association of diabetes with infection might have 
suggested an infection as the cause of the back 
symptoms. 

The importance of confidence in the surgeon and 
its effect on the psychology of the patient has been 
well brought out by Mock. Summed up he advo- 
cates handling each severely injured worker as a 
private case, explaining fully what is to be done and 
why, and following operation to constantly main- 
tain the morale of the injured man by encouraging 
talks and some form of manual occupation which 
can be done by the patient while in bed. 

The after-care of industrial accident cases is one 
of the most important and difficult duties of the 



96 HEALTH SERVICE IN INDUSTRY 

industrial surgeon, for in many cases the recovery 
is necessarily slow. No man can do well if lie is 
worrying over the support of his family and his 
final ability to work. The industrial surgeon must 
see that aid is provided the family when necessary, 
or that arrangements are made by which the wife 
can add to the income. In this part of the work 
the services of the visiting nurse are invaluable. 
As fast as the injured worker is able to resume 
any kind of work whatever, it should be provided 
him, not only for the effect on his morale, but also 
as a therapeutic measure. The war has proved con- 
clusively that restoration of function is more rapidly 
obtained by early active motion and consequent 
mobilization than by any other measure. The inter- 
est of the injured man in the work he is doing also 
plays an important part in the final result. A care- 
ful study by the industrial surgeon of the rehabili- 
tation methods used in France, England and Canada, 
during and following the war, will be of great value 
as a guide. 



CHAPTER VIII 

SICKNESS IN THE FACTOEY 

Sickness is the leading cause of absenteeism in 
industry. It not only causes absenteeism but also 
poor work and abnormal fatigue. Its effect upon 
the working classes has resulted in drastic relief 
laws in many countries. It is equally disastrous 
in its effect upon worker and management. The 
object of the health department in a factory is to 
prevent as much sickness as possible; to abort be- 
ginning sickness when this can be done, to prevent 
contagious disease entering the factory, and if it 
appears, to prevent its spread, and to instruct the 
workers in all matters connected with their health 
and welfare. Its object is also to treat minor cases 
of sickness which would not otherwise receive medi- 
cal attention and to give emergency treatment and 
advice in cases of sudden severe illness. It should 
endeavor in every way to co-operate with the fam- 
ily physicians of workers having chronic disease, 
and to carry out any suggestions made by the family 
physician as regards change of work or other mat- 
ters which are under its control. 

The medical work of the health department may, 
therefore, be divided into preventive, diagnostic, 
co-operative and curative. 

97 



98 HEALTH SERVICE IN INDUSTRY 

Prevention of Sickness 

The health department endeavors to prevent sick- 
ness in the factory: 

1. By a complete physical examination of all 
applicants for positions. 

2. By examining all workers who have been out 
because of sickness before they are allowed to 
return to work. 

3. By examining all cases of sickness applying at 
the factory dispensary with symptoms suggest- 
ing beginning sickness. 

4. By promptly isolating all cases of contagious 
disease. 

5. By periodic examination of all workers having 
beginning chronic disease, cardiac, renal or 
metabolistic and advising them as to work and 
mode of life. 

6. By periodic examination of all workers exposed 
to any special health hazard or poison in the 
factory. 

7. By inspection and control of ventilation, heat, 
humidity, light and other general working con- 
ditions falling under sanitation. 

8. By devising and controlling safeguards for 
special health hazards and poisons in industry. 

9. By spreading among the workers simple facts 
about health and disease prevention by personal 
talks and leaflets. 

The majority of these measures explain them- 
selves. Their reason is obvious and the technique 
apparent. The physical examination of all workers 
has been described in a preceding chapter. Workers 
who have been out because of sickness should be 
obliged to report at the nearest dispensary before 
being allowed to return to work. The nurse can then 
determine whether or not a doctor's examination is 



SICKNESS IN THE FACTORY 99 

necessary. Whenever a worker applies to the dispen- 
sary for treatment, the nurse should take a careful, 
concise history and if there is the least suspicion of 
real sickness being present, the temperature and 
pulse should be taken and the doctor called or patient 
sent to him. When a patient presents himself with 
contagious disease he should, of course,be sent home, 
the City Board of Health notified, and those work- 
ing near him examined and advised. Fortunately, 
contagious disease is rare in factories. In four 
years' experience of a factory employing 3,600 there 
were but two epidemics of contagious disease, one 
of mumps with 73 cases, 56 during the epidemic 
year, the other German measles with 27 cases about 
equally divided between two years. During the four- 
year record there was one case of small pox and 
87 vaccinations were done. 

The initial physical and subsequent examination 
is pretty sure to reveal any case of chronic disease 
in the worker. When such a condition is found the 
patient is given a very complete examination which 
is entered on a special form usually several pages 
in length. Following the examination the doctor dis- 
cusses with the patient the condition found, and in- 
structs him as to the general rules of life he should 
follow. If the patient's condition requires it, the 
doctor then arranges that he put himself in the 
hands of a private practitioner, and finally by con- 
sulting with the employment department so ar- 
ranges the patient's work that he can carry it on 
with safety to himself and others. 



100 HEALTH SERVICE IN INDUSTRY 



Health ^Safety 
Bulletin 

May 1916 



Norton Company 

Health and Sanitation Department 
Worcester, Mass. 



Fig. 7. A HEALTH BULLETIN 



SICKNESS IN THE FACTORY 101 

Many factories have in their processes of manu- 
facture some distinct health hazard. The Metropoli- 
tan Life Insurance Company has analyzed these 
and divided them into the following classification: 
a. Dust, b. Heat, c. Humidity, d. Poisons. When- 
ever such hazards exist they must be carefully 
studied by the industrial physician and every effort 
made to protect the worker against their effects. 
Not only must the exposed worker be protected but 
he must be periodically examined to determine 
whether or not he is being affected by his working 
conditions. A complete examination once in three 
months is a good rule to follow. 

A great deal of good can be done by quiet talking 
with the worker when he presents himself to the doc- 
tor at the dispensary. Every case should be treated 
by the doctor as he would a private patient. Many 
workers are foreigners and the doctor and nurse 
must use the simplest language in the kindest way 
if they wish to make the patient really understand 
the treatment he should carry out. In the majority 
of cases drugs play such an unimportant part that 
they may almost be eliminated, but the patient must 
be made to understand the importance of simple 
hygienic measures, diet, sleep and similar subjects. 

Health bulletins in the form of single sheets or 
folders written in simple language, easily under- 
stood and distributed in pay envelopes are of un- 
doubted value. Many factories have adopted this 
form of instruction. The subjects cover the com- 
mon diseases and injuries. (Fig. 7.) 



102 HEALTH SERVICE IN INDUSTRY 

Accurate diagnosis is the basis of all good medi- 
cal work. Poor diagnosis is more frequently due 
to carelessness than to lack of knowledge. In in- 
dustrial work as in hospital dispensary work, there 
is a temptation to inaccurate hasty diagnosis be- 
cause of the number of cases and the fact that many 
of the conditions presenting themselves are trivial. 
The industrial physician must always remember 
that he is in a unique position in medical practice. 
To him as to no one else is open the chance of study- 
ing disease in its earliest forms often before any 
pathology can be demonstrated. The general prac- 
titioner, according to MacKenzie, has the best op- 
portunity of studying early changes in heart disease 
and following cases through long periods of time. 
The industrial physician has an even better oppor- 
tunity for early diagnosis and continued study of 
cases. While it is true that there is a large turnover 
in every factory, it is also true that about fifty per 
cent of the workers remain employed over periods 
of from five to twenty years and can be re-examined 
and studied at any time convenient to the doctor. 
This opportunity for study should be used to its 
full extent. It is not as yet recognized by the pro- 
fession at large. The great opportunities of indus- 
trial medicine from the physician's standpoint con- 
sist of facilities for the study of disease in its very 
early manifestations and the ability to follow defi- 
nite pathological conditions over long periods of 
time. In order that definite diagnosis may be read- 
ily made, certain laboratory and diagnostic equip- 



SICKNESS IN THE FACTORY 103 

ment must be on hand, but this is never very ex- 
pensive nor does it occupy much space. Except in 
isolated communities a general hospital is usually 
available at not too great a distance where the more 
intricate chemical and X-ray examinations can be 
made. 
Co-operative Work 

In order to in any way do adequate medical work, 
the health department and its personnel must co- 
operate with the foreman, the worker and the gen- 
done away with. The worker must receive prompt 
must be modeled upon private practice, and yet the 
interminable waiting of private practice must be 
done away with. The worker must receive prompt 
attention, thorough examination, clear advice and 
be able to return to work in a minimum time. If 
the worker is given service of this kind he will use 
the dispensary freely and report back for further 
examination willingly when called for by the doctor, 
even when he is a piece worker. 

The doctor must co-operate with the foreman by 
not calling a man away from his work for an exami- 
nation unless the foreman says he can be spared. 
He must also obtain the co-operation of the foreman 
in changing the work of men who are handicapped 
by some physical disability. A foreman who is thor- 
oughly in sympathy with the health department and 
its ideals is a constant source of help to the doctor. 

Last and most important is co-operation between 
the industrial physician and the general practi- 
tioner. This relationship has only recently been 



104 HEALTH SERVICE IN INDUSTRY 

recognized. There has been a tendency in the past 
for the general practitioner to look askance at the 
industrial physician and the industrial physician to 
consider very little the problems of the general prac- 
titioner. For the good of the patient there should 
be close co-operation and this can easily be estab- 
lished if the problem is understood by both. If the 
practitioner is really interested in maintaining the 
health of his patient who is suffering from some 
chronic condition, or who has some physical defect, 
he can obtain very great assistance from the in- 
dustrial physician at whose factory his patient 
works. A short letter or telephone conversation 
puts the industrial physician in touch with the 
wishes of the patient's physician and he is able to 
assist by arranging the patient's work and, perhaps, 
by giving certain forms of treatment at the factory 
dispensary. For instance in a case of chronic ar- 
thritis, the industrial physician can arrange that the 
patient's work shall not be in cold or damp work 
rooms, that he receive systematic baking of the 
affected joints, and that his mouth be kept in good 
condition by the factory dentist. Moreover, if the 
patient does not seem to be doing well, he can send 
him back to his doctor with comments of value be- 
cause of his intimate knowledge of the patient's 
working conditions and reaction to environment. 

The industrial physician should use specialists 
outside of the factory with great freedom. It is his 
duty to see that patients needing special work be 
urged to have this attended to. Here, again, co- 



SICKNESS IN THE FACTORY 105 

operation is of the greatest value. The specialist 
frequently has certain changes of work to suggest 
or treatment to be given which can be carried out 
at the factory dispensary. 

In factories which exist in small towns the factory 
dispensary may easily become a medical center at 
which X-ray and laboratory work can be done at a 
trifling charge for the doctors in the community. 
Such work is now being done in a number of fac- 
tories and does a great deal not only to promote co- 
operation but to help the local practitioners obtain 
diagnostic data which they could not otherwise ob- 
tain. 

Curative Work 

This is confined entirely to the treatment of trivial 
sickness in an effort to prevent something more 
serious from developing. 

The most common diseases occurring in factory 
practice are those of the upper respiratory tract. 
This is the universal experience of industrial phy- 
sicians. In the author's clinic an analysis of the 
sickness covering a period of four years resulted as 
follows : 

Number of Cases of Sickness per 100 Employes 

1916 1917 1918 1919 

Respiratory 74 68 139 140 

Digestive 35 35 68 88 

Infection, Inflammation 

and Skin Disease 26 24 40 53 

Nervous 15 13 35 45 

Muscular 14 9 17 21 

Eyes 15 12 17 15 



106 HEALTH SERVICE IN INDUSTRY 

Ears 3 2 3 5 

Miscellaneous 6 23 26 26 

Total 188 186 345 393 

The predominance of respiratory and digestive 
diseases is noteworthy. The startling increase in 
number of cases during 1918 and 1919 is due largely 
to the influenza epidemic following which not only 
respiratory but digestive and nervous conditions 
seemed to increase in number. 

During the period the two leading diseases of the 
upper respiratory tract were rhinitis and tonsilitis. 
Influenza though epidemic and very severe in its 
effects ranked third in number of cases. The figures 
representing the total number of cases treated dur- 
ing the four years are as follows : 

Rhinitis 5052 

Tonsilitis 2654 

Influenza 2356 

In spite of the large number of cases of tonsilitis 
the number of cases of acute rheumatism and car- 
diac conditions was small, only 150 cases of acute 
rheumatism and 92 cardiac cases having been re- 
ported. The number of these which could be attrib- 
uted to tonsilitis has not been ascertained. Of the 
diseases of the digestive tract, constipation was by 
far the most frequent condition with gastritis a poor 
second. The complete list is as follows : 

Constipation 3060 

Gastritis 1569 

Indigestion 1426 

Gastro Enteritis 493 



SICKNESS IN THE FACTORY 107 

Enteritis 855 

Hemorrhoids 53 

Gastric Indigestion 115 

Appendicitis 28 

Miscellaneous 119 

The leading diseases in each of the other groups 
were: 

Infections, etc. Caries of teeth . . . 872 cases 

Skin Diseases Furunculosis 1028 cases 

Nervous Disease Headache 2976 cases 

Muscular Disease Myalgia 1360 cases 

Eye Disease Conjunctivitis . . .1271 cases 

Ear Disease Impacted Cerum. 229 cases 
Miscellaneous Disease Dysmenorrhea . . . 2269 cases 

On going over these diseases and figures it is evi- 
dent that except for influenza the majority can be 
more accurately classed as ailments than as diseases. 
It is also evident that they are of a character not 
only to cause considerable discomfort and disability 
but also to be in many cases forerunners of future 
more serious conditions. 

When the large number of these cases is con- 
sidered and the anxiety of both doctor and patient 
to arrive at a rapid but accurate diagnosis and 
some form of treatment recognized, it is evident that 
anything which will reduce time both in recording 
and dispensing is desirable. It has been found that 
a printed form, such as is shown (Fig. 8), is con- 
venient and time saving, the history, physical exami- 
nation, diagnosis and treatment being checked off 
with a pencil. The full advantage of this form of 
record will be shown when the general question of 
record keeping is discussed. In order that forms 



108 



Name 
Address 



HEALTH SERVICE IN INDUSTRY 

Norton Company Worcester, Mass. 

SICKNESS SLIP 

Health & Sanitation Department 

Time Treated 
No. Dept. 

Age M. S.W. Date 



Duration 
D. W. M. 


Phy. Exam. 


Diagnosis 




Treat 


Resp. 


Resp. 


Resp. 




Ac. Comp. 


Running Nose 


Coryza 


Coryza 




Bismuth Subnitr 


Cough 


Spts. on tons. 


Tonsilitis 




Brown Mixture 


Chills 


Crepitant r. 


Chr. Bronch. 




Rhinitis 


Expectoration 


Negative 


Ac. Bronch. 




C. C. & C. R. 


Sore Throat 


Sub. crep. r. 


Subac. " 




Castor Oil 


Feverish 


Granular Phar. 


Pharyngitis 






Hoarseness 




Dry pleurisy 




Chloroform & cloves 


Night Sweats 




Influenza 




Capsolin or liniment 


Laryngitis 




Dovers Powders grs. 


Dermatitis 






Abd. 


Abd. 


Abd. 




Sod. Salicylate 


Nausea 


Distended 


Gastritis 




Local anodyne 


Dizziness 


Tympan. 


Enteritis 




Paint I. & G. 


Vomiting 


Tender Ap 


Gastro ent. 




R. &I. 


Diarrhoea 


Mass in caecum 


Constipation 




Setter's Garg. 


Constip. 


Rash 


Appendx. 




Seidlitz Pulv. 


Abd. pain 




Indigestion 




Strapped 


Gen. 


Gen. 


Gen. 




Sputum Box 


Toothache 


Cavity 


Caries tooth 




Sent home 


Earache 


Impacted c. 


Otitis Media 




Silvol 


Conj. 




Chr. Rheum. 




Therap. lamp 


Nose bleed 


Ulcer of sep. 


Nose bleed 




Tr. Ginger 


Malaise 


T. 


Malaise 




Wash ears 


Gen. Pains 


P. 


Myalgia 




Massage 


_; . Rt. Chest 
Pam Lt. Chest 




Headache 






Headache 







Remarks: 

Fig. 8. A SICKNESS SLIP 

Filled in by Nurse or Doctor with a Series of Checks and Used 

to Record Cases of Minor Sickness. More Serious 

Sickness Is Noted in a Full Report 



SICKNESS IN THE FACTORY 



109 



such as this may be used and that dispensing be 
uniform, a certain amount of standardization must 
be employed. 

Every doctor has his own standard treatment for 
minor sickness, but the general proposition of stand- 
ardization can be carried out in any dispensary pro- 
vided every one in the department uses the same 
method of treatment, and only a certain number of 
drugs are provided. At the author's factory clinic 
the following is the regular practice and is given in 
order to suggest the basic idea: 



Respiratory System 

Pharyngitis 

Tonsilitis 



Local Treatment Systemic Treatment 
Paint with Tr. Pil. Rhei Comp. Pil. 
Iodine and Glycerin Cath. Comp. aa 1 pill 
equal parts. at night. Soda Sal- 

icylate gr. v q. 3.h. 



Coryza 

Trachitis 

Mild Bronchitis 

without Systemic 

Symptoms 



Advise warm cloth- Pil. Rhei - Pil. Cath. 
ing and protection Co. aa 1 pill at night. 
of feet. Alboline Pulv. Doveri gr. 10 
spray for nose. Ar- with hot lemonade 
gyrol 15% instilled with above. Tab. 



in eyes S. 0. S. 



Belladon. Dover's 
Powder Co. (Dela- 
field) one q.h., for 4 
doses then q.2.h. or 
Tab. Glyc. Co. for 
cough q.2.h. S. 0. S. 



Digestive System 
Indigestion 
Gastritis (Mild) 



None 



Pil. Rhei et Ipecac 

No. 3 (Roosevelt 

Hospital). 

2 after meals with a 

cup of hot water. 

Very light diet. 



110 



HEALTH SERVICE IN INDUSTRY 



Gastro Enteritis 

(mild) 
Enteritis (mild) 



Constipation 



Advise mustard Very light diet. Bis- 
paste to epigastrium muth Subnit. gr. 10 
at night. stat. with Tr. Zingi- 

ber dr. 1 in hot water. 
Bismuth Subnitr. gr. 
5 q.3.h. or each time 
bowels move. Castor 
oil oz. ss at night if 
no vomiting. 

Advise regularity Anti-constipating 
and special exercise, diet. Seidlitz Pulv. 
stat. Pil Rhei Co. 
Pil Cath Co. aa 1 
pil at night follow 
by Extr. Cascara gr. 
5 q.n. 



Nervous System 
Headache 



Paint forehead with 
local anodyne. 



Pil Acetanilid Co. 
gr. 1 every hour for 
3 doses. Treat con- 
stipation if present. 



There are standard forms of treatment for other 
conditions which are common but the above should 
give a clear idea of the method. All standard forms 
of treatment should be at the doctor 's hand and the 
pills and tablets should be ready in envelopes labeled 
with the name and amount of the drug and full 
directions as to use. Only a minimum number of 
tablets should be dispensed not only for economy 
but in order to have the patient return to the dis- 
pensary for further attention if a cure is not im- 
mediately effected. 



CHAPTER IX 

SANITATION 

The control of sanitation is the third function of 
the health department. Sanitation comprises the 
use of sanitary appliances, and deals with the con- 
trol of the external factors of environment which 
effect the health of the worker. The conditions re- 
quiring control are ventilation, illumination, tem- 
perature, humidity, drinking water, dust, and nuis- 
ances, especially those which may produce disease. 

The setting up of sanitary appliances and their 
maintenance in good working condition is the duty 
of the engineering department. The selection of the 
type of appliance, the study of its efficiency, the 
maintenance of cleanliness and the study of the 
effect of environment upon the health of the worker 
are sanitary duties. The purely health side of this 
work must be carried out by the industrial phy- 
sician, but the laborious portion should be placed in 
a separate sanitation department in charge of a 
sanitary foreman or inspector. 

The sanitary foreman is directly responsible to 
the chief physician. He has in large factories sub- 
foremen, and each sub-foreman is in charge of the 
sanitation in a certain section of the plant. For the 
cleaning of this section he has under his control a 

111 



112 HEALTH SERVICE IN INDUSTRY 

number of workers who give their full time to the 
work. 

It is the duty of the industrial physician to in- 
vestigate, and by co-operation with the engineering 
department, control: 

1. Ventilation. 

2. Illumination. 

3. Heat and Humidity. 

4. Dust. 

5. Drinking water. 

6. Disposal of sewage. 

Each of these will be discussed in detail. 
It is the duty of the sanitary inspector to control 
by the work of his force : 

1. Cleanliness of toilets and locker rooms 

2. Cleanliness of windows and electric lights 

3. Cleanliness of all floor space in order that dust 
hazard may be reduced 

4. Setting out and cleansing cuspidors 

5. Collection and disposal of litter and refuse 

6. Trapping of flies and extermination of vermin 

Ventilation 

When a number of individuals breathe air in a 
confined space certain chemical changes in the at- 
mosphere of the space occur. There is a reduction 
of oxygen, an increase of carbon dioxide, and an in- 
crease of possibly slightly toxic protein substances 
which are emanated from the skin and lungs. There 
are also physical changes consisting of increase of 
heat and humidity. The reduction of oxygen and 
increase of carbon dioxide, which occur in the aver- 
age factory even when poorly ventilated, are of no 
harm to the healthy worker. The carbon dioxide 



SANITATION 113 

content is, however, frequently used as an indicator 
of the general condition of the air in a given space. 
The protein emanations are the substances which 
cause the unpleasant odor, "stuffiness" and head- 
ache. The exact nature and degree of toxicity of 
these substances is as yet unknown. Physiologists 
lay special stress upon heat and humidity, the two 
physical factors, as being the true dangers of an 
overcrowded workroom. Combined they lower effi- 
ciency and are distinctly prejudicial to health. 

The object of ventilation is, primarily to reduce 
abnormal heat and humidity and to remove the pro- 
tein emanations. Secondarily, it acts as a stimulant 
by breaking up the warm stagnant air film which 
forms about the body, and by initiating currents of 
air which strike the skin at varying angles. This 
motion of air has been found to be most important, 
but must not be confused with the direct current of 
air which causes a " draught." The latter is uncom- 
fortable and unhealthful. 

There are three methods of ventilation in general 
use; by windows, doors, elevator shafts and other 
openings which occur in every building; by artifi- 
cially sucking air from the part to be ventilated ; and 
by forcing fresh air into the part to be ventilated. 
Frequently the last two are combined. Whatever 
method is used the industrial physician must see 
that it is efficient and that the air conditions in all 
departments of the factory are satisfactory. In 
those departments where there is question in his 
mind as to the efficiency of ventilation, carbon diox- 



114 HEALTH SERVICE IN INDUSTRY 

ide readings should be made, and where there ap- 
pears to be an abnormal amount of heat and humid- 
ity an hygrodeik should be installed and changes 
instituted following its readings. 

The special duties of the industrial physician in 
industrial ventilation consist of : 

1. Routine inspection to detect poor ventilation. 

2. Conference with the engineering department on 
questions of ventilation especially the installa- 
tion of new ventilation when this is contem- 
plated or repair of the old system. 

3. Routine temperature and humidity readings in 
special departments and co-operation with the 
engineering department in reducing this hazard. 

4. Inspection of hoods, suction apparatus, etc., for 
the removal of fumes or dust when these are in 
operation. 

5. Special attention to the ventilation, and the 
elimination of offensive odors, in toilets and 
locker rooms. 

To sum up factory air should not contain more 
than six parts of carbon dioxide in 10,000. , This 
means a supply of 3,000 cubic feet of pure air per 
person per hour. The temperature whenever pos- 
sible should not exceed 68° and the humidity should 
not exceed 72° wet bulb. 

Illumination 

There are two means of illuminating a factory, 
natural and artificial. Both are always employed. 
Natural illumination is obtained by windows, sky- 
lights, etc. It varies in different factories and in 
different parts of the same factory. The cause of 
variation is the amount of window or other lighting 



SANITATION 115 

space, the size of the floor space to be lighted, and 
the neighborhood of obstructions to light in the form 
of neighboring bnildings, wings, and so forth. 
Where there are no obstructions there is little 
trouble provided the builders have allowed an ade- 
quate amount of window space. Where there are 
obstructions the angle of incidence of light, that is, 
the angle formed by the admitted beam of light and 
a horizontal line passing through the window, is 
greatly increased. The result of this is increasingly 
poor illumination as the center of the room is ap- 
proached. This angle of incidence may be reduced 
by the use of ribbed glass or in extreme cases by 
the use of prism glass. During the "greater part of 
the working day in the winter months, and during 
some part of every day artificial lighting must be 
used. This is obtained from electric or mercury 
vapor light. Most factories prefer the former, 
using the Tungsten bulb and a proper reflector as a 
standard unit. The placing of the artificial lighting 
is arranged by the engineering department. Its 
maintenance should be controlled by the industrial 
physician. 

Illumination is measured in foot candles by a 
special apparatus called the photometer. ' ' One foot 
candle is the intensity of illumination produced on a 
surface one foot distant from a lamp of one candle 
power, the surface being at a right angle to the 
light rays." (Shop Lighting, National Safety Coun- 
cil No. 22.) 



116 HEALTH SERVICE IN INDUSTRY 

Certain standards of lighting have been agreed 
on as good practice. The National Safety Council 
recommends these as follows: 

Roadways and yard thoroughfares %o to % foot candles 

Storage spaces % to 1 foot candles 

Stairways, passageways, aisles 1 to 2 foot candles 

Toilets and washrooms 1 % to 3 foot candles 

Rough manufacturing, such as rough ma- 
chining, rough assembling, rough bench 

work, foundry floor work 2 to 4 foot candles 

Rough manufacturing involving closer dis- 
crimination of detail 3 to 6 foot candles 

Fine manufacturing such as fine lathe 
work, pattern and tool making, light 

colored textiles 4 to 8 foot candles 

Special cases of fine work, such as watch- 
making, engraving, drafting dark col- 
ored textiles 10 to 15 foot candles 

Office work such as accounting, type- 
writing, etc 4 to 8 foot candles 

There are three fundamental items of artificial 
lighting; intensity, distribution and absence of 
glare. Intensity can be measured, and to a certain 
degree controlled, by the industrial physician. This 
is carried out by controlling the maintenance and 
seeing that lights and reflectors are regularly 
cleaned, that burned out bulbs are replaced, and that 
dingy paint on the walls and ceilings is cleaned or 
renovated. 

Distribution of light is in the hands of the engi- 
neering department, but the industrial physician 
should see that the distribution is sufficient for the 
field to be illuminated. Most factories are under- 
illuminated. Absence of glare is most important 



SANITATION 117 

and can be controlled by the proper placing of 
shades and by selecting the proper type of reflector. 

There are three types of artificial illumination, 
direct, semi-direct and indirect. The first is almost 
universally used and is present in some part of any 
factory. It consists of the shaded electric bulb light. 
Semi-direct light is produced by placing the bulb in 
a semi-transparent bowl surrounded by a reflector. 
A small part of the rays of light pass through the 
bow], but the majority are reflected up to the ceiling 
and thence reflected about the room. 

Indirect lighting is when the bulb is hung in an 
opaque bowl lined with a reflector. The rays of light 
are directed or reflected to the ceiling and thence 
throughout the room. Both semi and indirect 
methods of lighting are employed in factories, the 
former more than the latter. The advantage of in- 
direct lighting is the absence of shadow, the disad- 
vantage is the high wattage lamps needed and num- 
ber of rather expensive fixtures plus the difficulty 
of cleaning. Indirect lighting requires a great deal 
of cleaning to be kept efficient. While many modern 
factories are using general lighting for all illumina- 
tion, the majority still use local lights for machine 
illumination. When these are used special care 
should be taken that the operators ' eyes are shielded 
from direct rays of light. The three dangers to be 
avoided are over-illumination, causing over-stimula- 
tion of the retina and contracted iris, under-illumi- 
nation producing eye strain, and reflected light from 
brightly polished metallic surfaces which tends to 



118 HEALTH SERVICE IN INDUSTRY 

confuse and to produce the effect of over-illumina- 
tion. 

Heat and Humidity 

The importance of this problem has been pointed 
out under ventilation. In many parts of most fac- 
tories heat considerably above 68° Fahr. is unavoid- 
able. Coupled with this is, frequently, excessive 
moisture making the working conditions most un- 
satisfactory. The more heated the air, the more 
moisture it will hold, and the greater the amount 
of moisture in the air, the more difficult it is for the 
human body to maintain its temperature equilib- 
rium. The temperature of the body rises under 
these circumstances, causing an artificial fever, and 
resulting in a distinct menace to health. Every 
effort should be made to keep the air in such depart- 
ments in active motion, using electric fans if other 
methods cannot be applied. The industrial phy- 
sician must meet the particular problem as it pre- 
sents itself and solve it to the best of his ability. In- 
asmuch as heat and humidity, far above the health 
limit, are necessary to many processes, attention 
must be paid to the personnel in these departments, 
and they should be re-examined and considered as 
men working in any department where there is a dis- 
tinct health hazard. 

Dust 

Many industries have dust as a health hazard in 
some part of production. Dust may be organic or 
inorganic. The former, though irritating, is not 



SANITATION 119 

seriously harmful, that is, it does not produce per- 
manent change in the lung as is frequent after long 
periods of inhalation of inorganic dust. Inorganic 
dust is harmful, producing, if inhaled over a long 
enough period of time, a connective tissue infiltra- 
tion of the lungs, closely resembling fibroid phthisis. 
The symptoms are those of phthisis without fever, 
there being cough, a gradual loss of weight and 
strength and rather marked dyspnoea on slight 
exertion. Except in special trades there does not 
appear to be a very serious danger from dust as it 
requires years of constant exposure to produce 
definite lung changes. Inasmuch as only those dust 
particles of 10 microns or less reach the lung, and 
as these fine light particles are for the most part 
removed by the exhaust system used in dusty trades, 
the hazard is further reduced. It is also important 
to note that the turnover is usually high in dusty de- 
partments, the workers preferring work elsewhere. 
This naturally prevents prolonged exposure. The 
most dangerous types of dust are the siliceous 
and zinc, of much less danger are dusts of softer 
substances as plaster of paris or coal. 

While fibrosis of the lungs is not common it is far 
from being a rare condition, and is prevalent in cer- 
tain trades especially among miners and stone cut- 
ters. Where the dust even when very hard can be 
removed by suction apparatus, the disease is seldom 
found. However, there is a tendency to an increase 
of respiratory disease in dusty departments as com- 
pared to non-dusty, and an irritating hard dust even 



120 HEALTH SERVICE IN INDUSTRY 

in small quantities will undoubtedly excite the light- 
ing up of an old tubercular lung process. 

The responsibility of the industrial physician in 
regard to dusty departments consists in an estimate 
of the hazard, a dust count if advisable, advice as to 
need of installation of an exhaust system, inspection 
of dust removing apparatus to determine its con- 
tinued efficiency, periodic examination of men work- 
ing continuously in dusty departments, and transfer 
to other departments of any who show a tubercular 
tendency even when no disease is manifest. 
Drinking Water 

The importance of a copious supply of clean 
drinking water in any industrial plant is self-evi- 
dent. In those plants where the factory receives its 
water through the city water supply, there is nat- 
urally no problem except when city water is con- 
taminated, a very rare occurrence. 

When the factory is isolated and has its own 
water supply, the industrial physician should test 
or have tests made of the water at regular intervals. 
In some cases where the water supply is impure, 
chlorinating the water will be necessary and fre- 
quent routine examinations should be made. 

The type of drinking fountain used is important. 
It is now considered advisable, when putting in a 
new installation, to use the type in which the stream 
forms an arc. The straight up and down fountain 
stream is not considered as clean, but it is more con- 
venient to use and, therefore, generally preferred 
by the workers. The temperature of the water 





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SANITATION 121 

should be between 45° and 50° F. when possible. Too 
cold water is very apt to cause gastro-intestinal up- 
sets when freely used by overheated workers in 
warm weather, while tepid water is unsatisfying 
and nauseating. 
Disposal of Sewage 

Here again the problem arises only in special con- 
ditions where there are no sewer connections. The 
industrial physician must co-operate with the engi- 
neering department in the installation and mainte- 
nance of any septic tank or other apparatus neces- 
sary. 

The actual work of the sanitary department, as 
previously stated, is carried out by the sanitary 
foreman and his force of workers. The organiza- 
tion of this work is often elaborate as shown in 
Fig. 9. 

The industrial physician will usually find a com- 
plete installation of toilets and locker rooms in the 
factory. These usually vary in quality in different 
parts of the works depending on the age of the in- 
stallation. His first work will therefore be to get 
the already existing appliances clean. This is often 
very difficult. After continued use with improper 
attention — for the care of sanitary appliances is 
usually nobody's business — he will find much of the 
equipment in need of minor repairs and the bowls 
covered with a yellow scale which is responsible for 
the unpleasant odor. The preliminary cleanup 
given by the force under the sanitary foreman 
should be very thorough. Plenty of soap and water 




Fig. 9. ORGANIZATION CHART OF SANITATION DEPARTMENT IN A FACTORY OF 4,000 EMPLOYES 



122 HEALTH SERVICE IN INDUSTRY 

for floors, walls and partitions, and a weak sulphuric 
acid solution to remove the scale from the bowls is 
the first step. 

After this preliminary cleaning the bowl should 
be washed daily with a soap powder, special atten- 
tion being given to the under side of overhanging 
edges beneath which scale collects. The condition 
of these places can only be seen by holding a small 
hand mirror in the bowl when many unsuspected 
catch places can be found covered with scale. After 
the washing, a spray of 1% Formalin should be used 
in the neighborhood. After a week's treatment fol- 
lowing this routine, a daily wash up with soap and 
hot water is all that is needed. 

If this routine is carried out a sanitary toilet is 
maintained such as is lacking in most factories. It 
is not the type of toilet but care and cleanliness 
which gives the sanitary result. Where new in- 
stallations are contemplated the Engineering De- 
partment should consult the doctor before deciding 
on the type of toilet to be installed. 

The National Safety Council makes the following 
recommendations : 

"Closets: Water closets should be of the in- 
dividual bowl type with individual water seal and 
should be made of white vitreous china or porcelain 
and not of enameled iron. Flush range closets 
which have been more or less extensively used are 
quite unsanitary and should under no condition be 
installed. The seat of each water closet should be 
made of wood or other non-heat-absorbing material 



SANITATION 123 

coated with varnish or water-proof paint to make it 
impervious to water. Seats made of enameled iron 
ware, porcelain or other heat absorbing material 
should not be used. For sanitary reasons it is 
recommended that the bowl be of the extended lip 
type and that the seat be open front and back. 

' ' There is qnite a difference of opinion regarding 
the best flush valve arrangement. Some companies 
which had installed seat-acting flush valve closets 
now favor a type in which the valve handle is placed 
alongside of and convenient to the user. A valve 
which may be tripped by foot-treadle has also been 
suggested. ' ' 

1 ' One closet for each 20 employes on the same shift 
is generally regarded to be sufficient. Where only a 
few are employed it is advisable to increase this 
ratio. ,, 

' ' Urinals : An adequate number of urinals should 
be placed throughout the plant convenient to work 
places to avoid loss of time required for men to walk 
to the toilet rooms. One urinal for each 40 males, 
or fraction thereof, is considered sufficient. Where- 
ever urinals are provided they should be in a suit- 
able enclosure. Provisions should be made for flush- 
ing out the rooms and keeping them in a sanitary 
condition. In each toilet room urinals should also 
be provided, the number depending upon their con- 
venience to workshops, and the number provided 
elsewhere in the plant. 

"Although the trough and basin urinals are used 



124 HEALTH SERVICE IN INDUSTRY 

in many plants, the vertical slab (individual stall) 
urinals are now recognized as best." 

The equipment of locker rooms is usually some 
type of steel locker. The best type provides good 
ventilation and a slanting top on which articles can- 
not be placed. The lockers should always be on legs 
raising them from the floor in order that the floor 
beneath them may be readily flushed with a hose. A 
bench between rows of lockers is a convenience for 
those changing clothes. The locker room is often 
used for a washroom as well as for lockers. (Fig 10.) 
The type of wash basin depends on the age of the 
installation. The National Safety Council recom- 
mends as follows: 

"The most desirable type of washing fixture for 
plant usage is a trough over which are placed hot 
and cold water pipes with faucets for washing, 
spaced not less than 24 inches apart, thus giving 
each man sufficient space for washing without 
splashing his neighbor. Double width troughs hav- 
ing faucets facing each side are in common use. 
Many companies place the single width troughs back 
to back; this arrangement providing a partition be- 
tween washers on the two sides. The troughs or 
basins should be made of porcelain enamelled iron 
or other impervious material which may be kept 
clean easily.' ' 

The sanitary force should clean locker rooms 
daily and keep metal work on washing appliances 
well cleaned and shining. Each locker room should 
be provided with at least one large waste can for 




Fig. 10. A GOOD LOCKER AND WASH ROOM 

Note 

1. Good light and ventilation. 

2. Steel lockers raised from floor. 

3. Shower baths at end. 

4. Faucets arranged for washing under stream of water. 

5. Cement floor and drain allowing hose washing. 



SANITATION 125 

papers, soap tins and other refuse and this should 
be emptied daily. 

Lockers should be cleaned once a month and 
whenever one is vacated. Each employe should 
have an individual locker. Ventilation, heating and 
daylight should be adequately provided. All these 
items require a certain amount of supervision and 
checking up by the industrial physician in addition 
to the actual work done by the sanitary force. 

The importance of keeping windows and electric 
lights clean was pointed out in discussing illumina- 
tion. The sanitary force should contain a certain 
number of window and lamp cleaners who should 
have a regular schedule of cleaning. They should 
also see that broken or defective lamps are replaced. 
In addition to cleaning toilets, locker rooms and 
lighting, the floor space of the whole factory should 
be thoroughly cleaned in order that dust may be 
reduced and tripping hazards eliminated. A certain 
amount of floor space should be assigned to each 
sweeper and he should be held responsible for his 
district. The same man should be responsible for 
the care and cleanliness of any cuspidors, drinking 
fountains, or other sanitary appliance. In most 
factories cuspidors must be installed. They may be 
of cardboard, but a large earthenware cuspidor with 
an inside glazed surface, half filled with a mixture 
of sand and chlorinated lime, is probably the most 
satisfactory. These cuspidors cannot be overturned, 
are easily collected on a hand truck, and can be 
rapidly washed out with a hose. The sanitary force 



126 HEALTH SERVICE IN INDUSTRY 

is also responsible for the collection of paper and 
refuse in the factory and the disposal of the same. 
It is often necessary to trap flies and rats. This 
is again a dnty which must be divided through the 
sanitary force. 

The sanitary foreman is responsible for the carry- 
ing out of these duties by his force and receives his 
authority from the chief physician. 

In small factories no such elaborate system is 
necessary; one or two men can be assigned all the 
sanitary work, these men reporting to one of the 
foremen or to the doctor. The important point is 
that sanitation, to be properly and economically 
carried out, should be the definite work of one or 
more individuals who have no other work to do. 
The advantage is that better work is done, the cost 
of sanitary work can be exactly figured, and some 
one is responsible for the sanitary condition of the 
whole plant. In many large plants sanitation is 
coupled with safety and both are controlled by an 
inspector of safety and sanitation. 



CHAPTER X 

SPECIAL PKOBLEMS 

There are three special problems which the health 
department has to consider. 

1. The physical condition of the higher executives. 

2. The study of health hazards peculiar to the in- 
dustry and their effect upon the health of work- 
men. 

3. The study of early manifestations of disease 
in workmen. 

The health department has excellent facilities for 
studying all three and if earnest in its efforts has 
an opportunity for some very interesting clinical 
research. In any factory the higher executives are 
the guiding hands which control the success of the 
business. If these men can be kept in good physical 
condition their work will always be the best they 
can turn out. If one or more is laboring under a 
physical handicap, work when kept up produces a 
nervous strain which eventually requires a pro- 
longed rest. 

Each member of the executive force should have 
a physical examination. This should be much more 
searching and complete than that given the work- 
men. The order of examination should be as 
follows : 

127 



128 HEALTH SERVICE IN INDUSTRY 

1. History — past and present. 

2. Physical examination — special attention to 

(a) Organs of special sense. 

(b) The heart — functional tests — electro-car- 
diagraph if necessary — blood pressure. 

(c) The lungs — X-ray all suspicious chests. 
Temperature every afternoon for a week. 
Three sputum examinations. 

(d) The digestion — special care to eliminate 
ulcer of stomach. 

(e) The kidneys — careful, complete, urin- 
alysis one twenty-four hour specimen, 
further examinations if necessary. 

(f ) The prostate and rectum. 

(g) The blood — in any cases where blood 
smear indicated. Wassermann when in- 
dicated. 

3. Check up any abnormal findings one month 
later. 

4. Re-examination and advice as often as indicated. 
Naturally special conditions found indicate 
special examinations. 

The value to the company of routine examina- 
tions of this type is evident. The loss of a single 
executive may cause considerable difficulty in the 
management of any department. The knowledge 
that all executives are in first-class physical condi- 
tion is a great asset, while it is equally important 
that a valuable executive who is physically slipping 
should appreciate his condition and co-operate with 
the doctor in warding off a breakdown. 

The Life Extension Institute, through its writings, 
has called attention to the large number of men 
at or about middle age in whom degenerative proc- 
esses of serious nature are just starting. These 
processes, if discovered, can usually be checked or 



SPECIAL PROBLEMS 129 

their progress greatly delayed by intelligent advice 
and management. The industrial physician is in a 
position to make examinations as often as they seem 
to be needed, and to supplement them by special 
examination at a general hospital if this seems neces- 
sary. This point, if no other, shows the great advan- 
tage of having the chief physician, or one of his 
assistants a member of the visiting staff of a neigh- 
boring general hospital. 

Vexed problems of diagnosis can be rapidly solved 
by sending the patient to the hospital for twenty- 
four hours where special X-ray, chemical, or other 
clinical investigations can be made. If there is 
enough evidence of trouble to indicate such an exam- 
ination the patient will readily assent. 

The records of the examination of executives 
should be kept in a special file by the chief physician 
and no one else should have access to them. Each 
case should be handled like a private case and rec- 
ords should be as inaccessible as in a practicing 
physician's office. 

The following examinations taken from the rec- 
ords of a large factory show the type of work which 
should be done. 

Mr. A. 

Date of examination, December 7, 1920. 

Physical findings: Mouth and throat, mild pyor- 
rhea. Several crowned teeth. Tonsils enlarged 
and ragged, no pus. Lungs, few coarse rales heard 
at left base, no change in breath sounds or in frem- 
itus. Heart, sounds of rather poor quality. Pulse 
120. Rhythm regular. Apex 1 cm. outside of 



130 HEALTH SERVICE IN INDUSTRY 

nipple line. Blood pressure 180/80. Rectum, small 
internal hemorrhoids. Slight pruritis. 

History: Complains at present of a slight pain 
in the small of the back. Pain worse after he has 
been on his feet for any length of time. Cardio- 
Respiratory — takes cold fairly easily, and notices 
he has a cough which hangs on following any slight 
cold. Frequent attacks of tonsilitis when young, 
none of late. Dyspnoea on exertion. Palpitation 
at times. Gets excited rather easily and at these 
times the palpitation is worse. Occasionally has a 
feeling of substernal distress. Genito-Urinary, 
Nocturia occasionally. 

Laboratory: Blood tests, hemoglobin 90%. Was- 
sermann negative. Blood urea nitrogen 12 mgm 
(normal). Two hour test for fixation of specific 
gravity, results given below. Tests show a ten- 
dency toward fixation of gravity in the afternoon, 
and it also shows a moderately increased night 
amount of urine. There was no albumen in any of 
the specimens and no blood, pus or casts in the 
sediment. 

Specific Salt Nitrogen 

Gravity Excretion Excretion 

1024 

1022 

1006 

1009 13.1 grs. 10.7 grs. 

1013 

1014 

1015 

Comment: This is a case of hypertension and 
apparently it is hypertension without any known 
cause. For lack of a better term these cases are 
called essential hypertension. As time goes on we 
can look for degenerative processes in the kidney, 
heart muscle or brain. A low salt, moderately low 
protein diet was outlined for this patient, and at 
the end of two weeks on such a diet his blood 
pressure was 140/80. It seems to me that he 



Time 


Amount 


8-10 


70 c.c. 


10-12 


110 c.c. 


12- 2 


465 c.c. 


2- 4 


490 c.c. 


4- 6 


315 c.c. 


6- 8 


200 c.c. 


8- 8 


585 c.c. 



SPECIAL PEOBLEMS 131 

should stick to this sort of a diet over a long period 
of time. Furthermore, he should be cautioned and 
should if possible rest for at least a half hour dur- 
ing the middle of the day. Examination of the 
heart should be made every few months. It is im- 
possible to say whether or not the degenerative 
processes can be delayed. 

Mr. B. 

Date of Examination, November 9, 1920. 

Physical Findings : Teeth — Considerable den- 
tistry, few carious roots. Chest — Funnel shaped 
breast. Lungs — Slightly increased, normal signs 
right apex, no rales. Extremities — Knee jerks not 
obtained. Evidences of old infantile paralysis. 

History: Complains particularly of nervousness 
associated with headaches. Unable to think 
straight. Condition getting worse. Mother died 
of Melancholia. Cardio-Respiratory — Occasional 
palpitation at night. No tendency to colds. Genito- 
urinary — No nocturia. Neuro-Muscular — Head- 
aches are frontal in type, more on the right side, 
not relieved by sleep, usually present upon awaken- 
ing. Sleeps poorly. Nervousness began one year 
ago. Following a two weeks' vacation May, 1920, 
felt better for four months. Attacks of nervous- 
ness and headache generally come together. No 
gastric upsets. Slightly depressed mentally. In 
addition in 1912 had an attack of so-called sciatic 
rheumatism. Has an occasional twinge of rheu- 
matic pain now. Twelve years ago slight inguinal 
hernia right, no trouble at present. 

Laboratory — Urine, Specific Gravity 1010. Other- 
wise normal. Blood hemoglobin 90%. Smear nor- 
mal. Blood Urea — Nitrogen 15 mgm. Blood Salt 
— 645 mgm. Blood Uric Acid — 1.5 mgm. These 
findings are normal with the exception of the Blood 
Salt which is somewhat elevated. 

On the supposition that some of the symptoms 
might be due to kidney changes, in addition to the 
above mentioned blood tests, a 2-hour test was done 



Time 


Amount 


8-10 


280 c.c. 


10-12 


85 c.c. 


12- 2 


440 c.c. 


2- 4 


140 c.c. 


4- 6 


225 c.c. 


6- 8 


270 c.c. 


8- 8 


625 c.c. 



132 HEALTH SERVICE IN INDUSTRY 

for fixation of specific gravity. The results of the 
2-hour test are given below. It will be noted that 
there is a good variation in Specific Gravity but 
that there is a fairly large night amount of urine, 
somewhat higher than we normally expect. Specific 
Gravity fixed during late p. m. and night suggest- 
ing kidney fatigue. 

Specific Salt Nitrogen 

Gravity Excretion Excretion 

1008 

1020 

1006 

1018 9.7 grs. 13.8 grs. 

1012 

1012 

1014 

Totals.. 2065 c.c. 

Slightest possible trace of albumen was found in 
two of the samples. The examination of the sedi- 
ments was negative. 

(1) Note that the mother died of Melancholia, and 
that the patient is mentally depressed. 

(2) It is possible that some of these cases are due 
to kidney changes and for this reason a moder- 
ately low protein (60 grams) low salt diet was 
outlined for this patient with the hope that if 
adhered to over a period of time it might have 
some effect on the symptoms. 

(3) A careful neurological examination is, it seems 
to me, indicated. 

Each industry has its particular hazard and each 
factory has its share of these hazards. Processes 
are common in which toxic or mechanically injurious 
substances are used and frequently the signs and 
symptoms which the patient presents make an abso- 
lutely unknown picture. The harmful agents of these 
various processes are rapidly being eliminated 



SPECIAL PROBLEMS 133 

wherever possible, but the industrial physician must 
be constantly on the watch and investigate any 
group of symptoms which suggest poisoning. 
Usually the hazard is already known and the symp- 
tom complex recognized. It is then necessary to 
watch for early symptoms and to endeavor to pre- 
vent definite disease or poisoning by recognition of 
early pathological changes. Thus among lead work- 
ers absorption of lead can be discovered by urine 
and blood examination long before the appearance 
of symptoms. 

Occasionally a group of cases will present a symp- 
tom complex suggesting a new disease. These cases 
should be very carefully noted, the symptoms classi- 
fied, and an attempt made to determine whether 
there is some substance in the process which is caus- 
ing the trouble. Thus obscure types of toxicosis 
such as manganese 8 and cadmium 9 poisoning have 
been recently investigated, their cause identified, and 
the method of their prevention determined. 

The industrial physician is placed in a unique 
medical position. He has an opportunity as afforded 
nowhere else in medicine to study the effect of work 
upon the human organism, and to observe the very 
beginning of disease. Workmen will avail them- 
selves freely of a well-conducted medical service 
consulting the doctor for a multitude of small ail- 
ments. As each visit to the factory dispensary and 
as at least one physical examination is recorded, 
the development of numerous diseases can be 
watched and an effort made to check them in their 



134 HEALTH SERVICE IN INDUSTRY 

early stages. There is also the opportunity for the 
observation of chronic disease conditions over 
periods of years, and the study of groups of similar 
conditions can be readily made. The amount of 
material and the ease with which this can be 
gathered together at any time is a thing as yet unap- 
preciated by the majority of the profession. Thus, 
if the chief physician wishes to investigate the effect 
of work on hearts having a mitral systolic murmur, 
he can have the entire group sent to the dispensary 
at ten minutes notice. If he wishes to find out the 
end result in a series of fractures it is equally easy. 
A large factory with which the author is connected, 
is now reviewing the end result of all serious acci- 
dents of the previous year, and is making re-examin- 
ation of all defective hearts, paying special attention 
to the functional power of the mycocardium and its 
reaction to different forms of work and exercise. 
Following this an investigation of hernia cases will 
be made, determining the end results in all operated 
cases and the condition of workers who have not 
had operation. The same factory will shortly start 
an X-ray lung examination of a number of its 
employes who have been exposed to abrasive dust 
over a period of years. It will be seen from this 
that the opportunities for investigation are almost 
limitless, and that lack of a sufficient force of medi- 
cal workers is the only handicap. It is to be hoped 
that some of the problems of medicine will in future 
years be solved through the industrial medical 
department and laboratory. 



SPECIAL PROBLEMS 135 

The work of the health department will be incom- 
plete without a good record system. In previous 
chapters the record system has been mentioned 
and its importance indicated. Unless very complete 
records are kept the mass of information which is 
being obtained is valueless. Every factory health 
department has a different system. In many ways 
they are similar but none are exactly alike. The 
important points in a system are : 

1. Accuracy. 4. Elasticity. 

2. Brevity. 5. Economy. 

3. Availability. 

It is hardly necessary to dwell on accuracy. The 
exact position of injuries must be stated and the 
exact result of the injury recorded. Similarly physi- 
cal examinations and special investigation must be 
recorded with detail and accuracy. 

Brevity means getting in all necessary facts in 
the fewest possible words. Positive findings only 
need be recorded. Date and time as well as name of 
the doctor, or the nurse, treating the case should be 
entered. 

Availability means that a record can be found in 
one minute or less. 

Elasticity means that the record system can be 
enlarged or contracted at will and that individual 
records can be added to indefinitely. 

Economy means running a record system with 
the least trouble and clerical work, using the small- 
est number of clerks possible. 

As there are many systems some good, and some 



136 HEALTH SERVICE IN INDUSTRY 



" "\ 

Health & Sanitation Department. Norton Company, 

Name 


Worcester. Mass. 

Age 


Address 


DepL No. 


Date 


Gen. Appearance 


i p 
Eyes: Vision Dist 1 Ft. "\ . 


Ears: Hears Watch I . 


Inches 
Inches 


Nose 


Throat 


Tongue 


Teeth 


Neck 


Chest Contour 


Heart 


Pulse 


Blood Pressure 


Lungs 




Abdomen 


| Upper 
Lxtrem. N , , 

1 Lower 


Ing. Reg. 


G. U. 


Spine 


' 


Skin 


Height Weight 


Joints 





Fig. 11. PHYSICAL EXAMINATION ENVELOPE 



SPECIAL PROBLEMS 137 

bad, we will describe a simple system which is the 
result of ten years' actual experience and which 
has proved satisfactory and economical. The unit 
of the system consists of a single manilla envelope 
5% by 8% inches on the face of which are printed 
the physical examination headings. The back con- 
tains space for recording transfers and date of dis- 
charge. Within the envelope, which opens end up, 
are placed the cards bearing the sickness and acci- 
dent record of the worker, any letters from ontside 
physicians, specialists' reports or other medical 
information. Thns each envelope has on its face 
the physical examination of the worker on entrance 
to the factory with his complete subsequent record 
within. (Fig. 11.) 

The method by which the sickness and accident 
record is built up is as follows. In each sub-dispen- 
sary as well as in the central dispensary, there are 
two forms, one for sickness and one for accident. 
(Figs. S and 12.) Each form is so arranged that 
after the history is taken, the doctor or nurse can, 
by a series of checks, designate the injury, its site, 
diagnosis and treatment, or in case of sickness the 
history, physical examination, diagnosis and treat- 
ment. These forms are in a block and torn off as 
needed. Every dressing is thus recorded and 
initialed by the doctor or nurse treating the case. 
TVhen more detail is needed in special cases the back 
of the slip is used for full long-hand notes. 



138 HEALTH SERVICE IN INDUSTRY 

Norton Company Worcester, Mass. 

no. ACCIDENT SLIP 



Name 

Address 

Location 

What patient was doing 



Health & Sanitation Department 

Age Dept. 

M. S. W. Date 

Time Accident 
Time Treated 



Exp. 
Occ. 



What happened 



- 


Injury 




Site 




Treatment 




Condition 




Return 


Lac. wnd. 




Rt. Lt. 




G.&I. 


- 


Healing 


- 


Today 


Abrasion 


- 


Eye. O'Clock 


- 


D.D. 


Infected 


Tomorrow 


Contusion 


Hand 


W.D. 


— 


Clean 


D. after T.M. 


Puncture 




Wrist 




F. B. R. Coc. 


Improved 


See Doctor 


- 


Incised 


- 


Elbow 


- 


Sp. Drops 


No Change 


Report 


Sprain 


Forearm 


Silvol 


Lost Time 


R. to work 


Strain 




Foot 


Strapped 




Released 


Days 




Burn 




Ankle 


Splint 




Main Hosp. 




Weeks 




Foreign Body 


- 


Knee 




Sutured 


- 


Advised Xray 


- 


Months 




Fracture 


1.2,3,4.5 




Sutures rem. 




Discharged 


- 


F. B. Conj. 




Finger 




T. Lamp 














Toe 




Massage 
















Back 




Wax 











Fig. 12. ACCIDENT SLIP 

For the Quick Recording of Accidents. It May Also be Used 

for Recording Treatments 



SPECIAL PROBLEMS 139 

Each nurse brings to the central dispensary at 
noon and at night, the forms she has filled ont. 
These are immediately arranged in alphabetical 
order by the clerk. She then goes to the central file 
and takes from the physical examination envelope 
the last record card on each case. Upon these she 
transcribes the record on the form slips. These 
cards are then filed in a drawer near her desk as 
"live" cases. In case of redressing or retreatment 
the card is simply taken from this live file. When a 
case is discharged the card is transferred from the 
live file to the main file being replaced in the physi- 
cal examination envelope. 

The main file is cleared weekly from a list of dis- 
charges sent to the health department by the employ- 
ment department. Monthly reports can be readily 
made from the cards in the live file by not re-filing 
until the monthly report statistics have been taken 
off. 



Forms for special examinations as heart, lungs, 
special industrial diseases or poisoning, clinical 
reports, X-ray reports and similar data are filed in 
the individual envelope as received. It has been 
found that the space on any general physical exam- 
ination form is much too small for detail. In order 
that adequate records may be made, there should 
be special forms for recording heart, lung, and 
special examinations. 



140 



HEALTH SERVICE IN INDUSTRY 



Heart Questionnaire for Recording All Cases of 
Diseased Heart 

Name Age No. 

Address Dept. Date 

Present Complaint 

Family History 

Past History Date and duration of Illness 

Rheumatic fever 

Tonsilitis 

Influenza 

Typhoid fever 

Other illnesses 
Habits 

Appetite and digestion 

Bowels 

Kidneys 

Alcohol (amount) 

Tobacco " 

Food " 

Tea " 

Coffee " 

Sleep " 

Physical exercise ("Gardening 

other than that of <[ Walking 

occupation [Dancing, etc. 

Venereal History 

Gonorrhoea Date of Infection 

Syphilis Duration and nature of treatment 

History of Heart Trouble 

Present Condition 

Shortness of breath 

Palpitation 

Dizziness or giddiness 

Precordial pain 

Fainting 

Swelling of ankles 

Fatigue 
Nature and Description of Present Work 

How does it agree with patient 



SPECIAL PROBLEMS 



141 



Physical Examination Thyroid 

1. Before exercise 

(a) Inspection 

Respirations — Normal — Increased 

Chest — contour 

Cyanosis 

Pulsations 

Bulging precordium 

Apex beat visible 

Sweating 

(b) Palpation 

Pulse rate and character 
Apex beat palpable 
Thrill 

(c) Percussion 

(d) Auscultation (Breath to be held in expiration) 
Heart sounds 

Murmurs present 

Effect of posture Before Ex. After Ex. 



Blood Pressure 



Systolic 
Diastolic 
Pulse Pressure 



2. After Exercise A. Simple 

Pulse rate and character 
One minute after exercise 
Cyanosis 
Breathlessness 
Pain 
Other symptoms 

No. of hops 
Rating (degree of tolerance) 
Good Fair Poor 

Final Diagnosis: 
Prognosis : 
Treatment : 



B. Strenuous 



No. of lifts 



Good Fair Poor 



142 HEALTH SERVICE IN INDUSTRY 

Lung Questionnaire for Recording All Cases of 
Diseased Lungs 

Name No Dept Date 

S. M. W Age Residence 

Family History of Tuberculosis or other Lung 
Disease 

Previous History 

Diseases of Childhood 

Lung or Gland Disease 

Other Severe Diseases 

Venereal Disease 

Habits 

Tea Appetite 

Coffee Bowels 

Tobacco Catamenia 

Alcohol 

Present illness 

Date and Mode of Onset 

Cough 

Expectoration 

Haemoptysis Pain 

Loss of Weight Weakness 

Afternoon Fever Shortness of Breath 

Chills Sore Throat or Hoarseness 

Night Sweats Insomnia 

Physical Examination 

Height Weight Best Weight 

General Appearance 

Adenopathy 

Contour of Chest 

Symmetry 

Expansion 

Lungs 

Tactile Fremitus 

Percussion 

Resonance 



SPECIAL PROBLEMS 
Auscultation 



143 



Vocal Fremitus 

Rales Description of 

Sputum Positive Negative . 

Heart Blood 

Urine 

Diagnosis 



Lead Questionnaire for Recording All Workers Ex- 
posed to Lead Poisoning 



Name 


Age 


Address 


Department 
Health 


good 

fair 

poor 


Experience therein 
and previous experience 
in handling lead 


Appetite 


good 

fair 

poor 




Digestion 


good colic 

fair eructation gas and 

poor regurgitation of fluid 


Bowels 


regular 
constipated 
or loose 
alternating < 
or diarrhea 


constipation 


Strength 


vigorous 
weak 




Swelling of 
ankles 


present 
absent 





144 



HEALTH SERVICE IN INDUSTRY 



Physical Examinati 


on 




General appearance robust 


frail 


Pallor 


present 
absent 




blue line 


present 
absent 




Mouth 






teeth 


good 
fair 
poor 




Heart Murmurs present 


description of 




absent 




Arteries rate of pulse sclerosis present degree 




absent 




systolic 




Blood pressure 


diastolic 
pulse pressure 
distended 




Abdomen 


level 
scapheid 




Peri-umbilical tenderness present 






absent 




Extremities 


extensor weakness present 




or wrist drop 


absent 




oedema ankles 


present 
absent 


Blood 


stippling 


present 
absent 


Urine 


lead 


present 
absent 




nephritis 


present 
absent 



The unit envelopes with their contents are filed 
alphabetically in a central file. Wherever the record 
notes a serious defect a colored marker or flag is 
attached to the upper edge of the envelope. Differ- 
ent colors indicate different defects. In this way 



SPECIAL PROBLEMS 145 

the clerk can rapidly gather the whole group of 
defective hearts, lungs, hernia or whatever is called 
for. 

As men are being constantly discharged and fre- 
quently rehired, a large "dead" central file is needed 
in which are filed the envelopes of those men who 
are discharged each week as determined by a weekly 
list from the Employment Department. 

The investigation of sickness and accident cases 
at their homes by the visiting nurse service has been 
noted. The record of these cases coupled with the 
record of individual time lost, as recorded by the 
cost department from the time clock cards, forms the 
basis of many interesting medical statistics. 

In a large factory the following statistics were 
worked out in detail, charted and curved last year. 

1. Report on sickness for 1916, 1917, 1918, 1919 
presenting the record analysis of data covering 
the cases of illness reported as having occurred 
among the plant force during those periods. 
The extent of the disability discussed both with 
reference to the comparative amount from year 
to year and in regard to the measurement of 
the occurrence by disease groups within each 
year. These groups also compared for the four- 
year period. 

2. Report on absence from sickness July, 1919, to 
July, 1920, presenting a record of the absence 
occasioned by illness during the year relative 
to extent of disability, nature of illness, period 
of absence, and comparative prevalence of cer- 
tain ailments among departments where similar 
physical conditions attend the occupations. Data 



146 HEALTH SERVICE IN INDUSTRY 

also shows the occurrence of disability by 
months and the rate of return to work by those 
affected. 

3. An analysis of the data pertaining to the dusty 
departments to derive the relation between the 
period of employment and liability to sickness. 

4. Analysis of cases of hernia operated during 
past year, giving etiology, duration of stay in 
hospital, duration of inability to work, and end 
results. 

Different problems of this type are constantly 
arising which can be rapidly analyzed, producing 
extremely interesting data. 



CHAPTER XI 

COST OF MEDICAL SUPEKVISION AND ECONOMICS OF 
INDUSTKIAL HYGIENE 

The cost of a health service in industry must be 
divided into the cost of the dispensary system, the 
cost of the visiting nurse service, and the cost of 
sanitation. Each will be considered in order. 

The present cost of maintaining a complete, well- 
running medical department is approximately six 
dollars per position in the factory per year. Thus 
in order to find the cost, the average total number 
of employes for the year should be multiplied by 
six dollars. This is less than the most expensive 
medical services, but it is higher than many which 
are now being carried on so that it is a safe conser- 
vative figure. This figure does not cover the initial 
expense of dispensary equipment. It can only be 
used when considering the force as one in continuous 
operation. That is, if a force of 3,000 is suddenly 
reduced to 1,000 it takes quite a long time to make 
the corresponding reduction in medical department 
expense. On the other hand the force may usually 
be considerably increased before added expense is 
incurred. In other words it is easier to expand 
without added expense than to contract with reduc- 
tion of expense. 

147 



148 HEALTH SERVICE IN INDUSTRY 

Moreover these figures can be generally consid- 
ered only as prices, salaries, etc., vary in different 
parts of the country. In the accompanying table an 
effort has been made to indicate the more important 
items of expense at the average of nineteen twenty- 
one. 

Estimate of Expense of Medical Personnel, etc., 1921. 



No. 
of Em- 
ployes 


No. of No. of 
Full- Part- Cost 
Time Time of 

Doctors Doctors Doctors 


No. of 
Full- 
Time 

Nurses 


Cost 
of 

Nurses 


No. 
of 

Dis- 
pens- 
aries 


Initial 

Cost 
of Dis- Cost of 
pensary Supplies 
Equipment 1 Tear 


Total 
Medical 

Cost 
Per Tear 


200 





1 $360 








1 


$250 


$240 


$1,200 


500 





1 540 








1 


500 


700 


3,000 


1000 





1 1,200 


1 


$1,560 


1 


1,000 


1,200 


6,000 


3000 


1 


2 5,400 


3 


4,680 


3 


2,000 


3,600 


18,000 


5000 


1 


3 10,400 


6 


9,360 


5 


4,000 


6,000 


30,000 



The cost of establishing and equipping a dispen- 
sary, and its running cost, are very difficult things 
to figure owing to the constant change in prices. The 
figures here given are decidedly estimates. 
Salaries of Doctors 

There is more variation in the salaries paid in- 
dustrial physicians than in any other item. 
Part-time Doctors 

When working on a basis of two or three visits to 
the plant per week the average fee is three dollars 
a visit, each visit being about one hour. A special 
fee of three dollars is paid for calls to plant outside 
of visiting hours. When the part-time doctor visits 
the plant daily, spending approximately three hours 
a day, he receives $1,200 to $1,800 a year for his 
services, but if he is a highly-trained man, specially 
desired, his salary may go much higher. 



COST OF MEDICAL SUPERVISION 149 

Full-time Doctors 

A doctor giving full time to industry receives 
from $1,800 to $5,000 a year depending on the size 
of the factory and the importance of his position. 
Thus a man just out of inedical school or hospital, 
starting in industrial medicine, receives much less 
than a fully qualified industrial physician. In the 
large plants employing over four thousand employes 
the chief physician 's salary may be $10,000 or more. 
It must always be remembered that salaries in in- 
dustrial medicine are net, that is, all equipment, 
transportation, supplies, etc., are without cost to 
the physician. He has no expenses whatever. 

The salaries of industrial nurses, whether dis- 
pensary or visiting, seem to average about $30 per 
week. This figure applies especially to the eastern 
states. It is said to be higher in the middle-western 
states. 

In March, 1920, an investigation of nurses' sal- 
aries in twenty large factories in New England and 
elsewhere found the average wages as follows : 

Yearly Average for Female Dispensary Nurse $1,438.00 

Yearly Average for Female Visiting Nurse 1,441.00 

Yearly Average for Male Dispensary Nurse 1,858.00 

(Made by Secretary of New England Conference 

Board of Industrial Physicians.) 

The dispensary nurse usually has the added per- 
quisites of uniform, laundry, and expenses to any 
nurses' conference she attends. All nurses receive 
two weeks vacation per year with pay and indefinite 
sick leave when necessary. In all cases graduate 
nurses only are considered. 



150 HEALTH SERVICE IN INDUSTRY 

Each visiting nurse has in addition the use of a 
company automobile during working hours. The 
cost of the visiting nurse service will, therefore, be 
$1,441 per year for each nurse plus the cost of office 
space and fixtures, and automobile expense. The 
most satisfactory type of car has been found to be 
the Ford coupe which costs about $800 delivered. 

The cost of sanitation is impossible to estimate for 
industry as a whole. At a large factory employing 
about 4,000 workers, it amounted to twenty-one dol- 
lars per year per position in the factory in 1920. 
This included every cleaning expense, floor sweep- 
ing, paper baling, etc. The expense in this factory 
was somewhat greater than the average because of 
the large floor area and the dusty character of the 
business. The average factory superintendent will 
be surprised to find how great is the expense of 
cleaning when it is separated from general depart- 
mental expense where it is usually carried and 
buried. 

In the past four years three comparatively com- 
plete surveys of the cost of Health Supervision in 
industry have been made. The first was made by 
M. W. Alexander for the Conference Board of Phy- 
sicians in Industrial Practice in 1917. This survey 
of ninety-five factories found the average annual 
cost of medical and surgical supervision per em- 
ploye to be $2.21. The majority of these factories 
were not, however, carrying on medical supervision 
as outlined in this book, and costs have mounted 
steadily since the above statistics were compiled. 



COST OF MEDICAL SUPERVISION 151 

The second survey was made by Selby, in 1918. 
One hundred and seventy industrial establishments 
were visited. Though making a very complete in- 
vestigation and discussing numerous costs found, 
no compilation of expense is made. 

The third survey was made by Wright in 1920 for 
the Cleveland Hospital and Health Survey. "Wright 
investigated 1,521 factories. He found 72 had some 
type of medical service. He says : l ' There are sev- 
eral plants in Cleveland efficiently applying cost 
accounting to medical departments and it is in these 
few plants alone that there is definite knowledge of 
the total outlay for medical work. Other firms may 
roughly calculate the cost by guessing at the value 
of medical supplies purchased or on hand and add- 
ing to that amount the salaries of personnel. A 
number of firms stated the cost to be in the neigh- 
borhood of five dollars a year per employe." 

Wright rather doubts the accuracy of the above 
for reasons previously stated. He goes on to say: 
"In one large establishment the cost is $10.92 a year 
per employe and in another $11.23. Such amounts 
are probably not excessive at the present time if the 
service is comprehensive and of a high order.' ' 
Drinker 10 in a review of the economic aspects of in- 
dustrial medicine in 1920 says: "At the present 
time we know of two establishments where the cost 
is between $6 and $7 per employe, and there is cer- 
tainly no disposition to curtail the service offered in 
either instance. It is probable that a figure of $5 
per employe more nearly represents the average 



152 HEALTH SERVICE IN INDUSTRY 

total cost of well-administered industrial medicine 
at the present time. ' ' 

From an economic point of view it is interesting 
to compare the figure of $6.20 per position in the 
factory, a rate of actual experience for the year 1920 
in a large Worcester factory, with the expense of 
medical care estimated by the National Industrial 
Conference Board in its table of the average mini- 
mum cost of living at a fair standard for a single 
man in Worcester, Massachusetts, in June, 1920. 

Medical supervision in factory one year includ- 
ing— 

Physical examination on entrance and subsequent 
examinations. 

Treatment (complete) of all accidents. 

Treatment of all minor sickness. 

Pathological and X-ray work $6.20 

Medical care of single man in Worcester living at 
minimum cost at a fair standard, one year $18.20 

The factory medical work which is very complete 
costs $12 per year less than average medical 
care for the same period in the same city. 

Having considered the costs of medical super- 
vision, what are the benefits ? They may be divided 
into those which affect management and those which 
affect the worker. All authors who have written on 
this subject agree on the economic value of medical 
supervision to management and the difficulty of 
showing this in figures. Mock sums up the benefits 
to management as follows : 

1. Reduces time loss due to sickness and epidemics. 

2. Reduces compensation for accident, disability, 
deformities and death. 



COST OF MEDICAL SUPERVISION 153 

3. Increases output by steadier working force. 

4. Decreases hiring of new employes at a great 
financial saving. 

5. Increases the number of old employes with their 
constantly increasing value. 

6. Increases general efficiency of force. 

7. Secures good will of employes. 

It will be readily seen how few of these advan- 
tages can be translated into monetary valne. Mock 2 
collected " statistics from ten large industries, hav- 
ing excellent medical staffs, which examine all ap- 
plicants for work." These statistics show that 9.7% 
of all applicants (118,900) were rejected for work 
because of disabilities and that by this rejection 
alone $144,155 was saved. He bases these figures 
on Alexander's estimate of the cost of turnover at 
$35 per employe, believing that each rejected em- 
ploye would have left the company within six 
months of being hired. 

Howen using the same figures has attempted to 
show the exact saving to a factory of 1,000 employes, 
resulting from a well-organized medical depart- 
ment. He bases his figures of saving on Mock's 
10% rejection figure and Alexander's estimate of 
$35 per employe as the cost of turnover, and his ex- 
pense figures on the investigation of the Conference 
Board of Physicians in Industry on the cost of medi- 
cal supervision in 95 large factories. His balance 
sheet is as follows: 

u Ina Typical Plant of 1,000 Employes, Suppose 
the Value to the Employer of each Employe-Day, 
above "Wages Paid, is $2. 



154 HEALTH SERVICE IN INDUSTRY 

A conservative calcula- A careful investigation 

tion places the in 95 representative 

plants places the 

Saving from lessened ill- Cost of Medical Super- 

ness due to Medical vision at $2.21 per 

Examination of Appli- Employe per Year, or 

cants at $ 683 for this plant of 1,000 

Saving due to Prevention Employes $2,210 

of infection at 2,442 

Saving in Workmen's 
Compensation Insur- 
ance Premiums 1,105 Balance Saved 2,020 



$4,230 $4,230 

And besides this there are the many intangible 
savings due to such causes as lessened illness 
through dissemination of health literature, and 
through prompt treatment at the beginning ; greater 
output through increasing physical vigor; and in- 
creased goodwill on the part of the employes.' ' 

The author believes that 10% is too high a figure 
for rejections and that rejections should not be used 
as a basis of determining the economic value of 
medical supervision. The real value should rest 
upon: 

1. Reduction of absenteeism as a result of 

(a) Prevention of sickness. 

(b) Prevention of infection following in- 
juries. 

(c) Proper treatment of serious injuries. 

(d) Assurance of worker in cases of exag- 
geration or imaginary illness. 

2. Reduction of accident insurance rate as a result 
of a well-equipped medical service. 

3. Preservation of the health of valued workers 
and executives. 



COST OF MEDICAL SUPERVISION 155 

4. Prevention of "unhealthy working conditions" 
and "lack of medical care" being used as a basis 
for strikes or other labor disturbances. 

5. Increased "good will" of worker for company. 

Considering each in a little more detail. 

1. The experience of industrial physicians is that 
absenteeism due to sickness and accident can 
be reduced between 25% and 50% as the result 
of a well-run health department. 

2. A definite reduction of rate is made by accident 
insurance companies when the policy holder 
maintains a health department. 

3. The preservation of the health of valued 
workers and executives cannot be measured in 
dollars and cents. The early discovery of be- 
ginning disease and its prompt cure in the case 
of an important executive may be of more value 
than the entire cost of the health department 
for a year. 

4. A well-run health department inspires confi- 
dence among the workers and content with their 
surroundings. No cause of dissatisfaction from 
working conditions is likely to arise. This is 
worth a great deal to the company. 

5. A good medical service is always a source of 
satisfaction to the worker and a firm bond be- 
tween man and management. 

The benefits of medical supervision to the worker 
according to Mock 2 are that it : 

1. Discovers disease early — more rapid and surer 
cure. 

2. Discovers organic disease which can be con- 
trolled. Prevents overwork and hazardous 
occupations for these. 

3. Prevents disease by discovering focal infections 
and danger signs. 

4. Provides protection from contagious disease. 



156 HEALTH SERVICE IN INDUSTRY 

5. Provides suitable work according to physical 
condition. 

6. Prevents accident by removal of cause in em- 
ploye. 

7. Provides better medical care when sick. 

8. Provides better surgical care when injured. 

9. Reduces suffering, permanent disability and 
death rate. 

When we consider the results as a whole we see 
that the entire community benefits by the improved 
conditions of the worker, that the local board of 
health is assisted in its work, and that the lessons 
learned by the workers are carried to their homes 
and have a definite effect on the health of their 
families. 

There are few manufacturers who, if they realize 
the all-round advantages of maintaining a pro- 
gressive factory health service, will begrudge the 
six dollars per employe per year necessary to put it 
into operation. It is the author's belief that a well- 
run health service returns yearly a cash dividend 
from time saved and disease prevented alone with- 
out considering in any way the great value of many 
of the less easily estimated but none the less definite 
benefits. One of the strongest proofs that this is a 
reasonable statement is that the National Industrial 
Conference Board 4 upon investigation of a large 
number of industries found not only that the ma- 
jority were providing medical service, but that the 
service was being enlarged. To quote the conclu- 
sion: 

"Judged by the experience gathered among New 
England industries, the value of certain phases 



COST OF MEDICAL SUPERVISION 157 

of industrial medical work is quite fully recognized. 
With few exceptions plans were under way for an 
expansion of the work, either by adding to the 
quarters, the staff, or the character of the work." 

In the majority of states a Workman's Compensa- 
tion Act is in force. This requires carrying of com- 
pensation insurance by the factory. One of the 
largest insurance companies in the East in a pam- 
phlet entitled, "Surgical Service for Plants having 
Fifty to Fifty Thousand Employes' ' makes the fol- 
lowing statement : 

"The advantages to be gained by employers 
through the installation of a plant hospital or first- 
aid room are : 

1. An increased production through: 

a. Saving in time by having injuries dressed 
and redressed at plant instead of at office of 
private physician or at public hospital. 

b. Practical elimination of lost time and labor 
turnover that result from neglected or im- 
properly treated injuries. 

c. Saving in time by having doctor and nurses 
prescribe for slight illnesses that might 
otherwise take employes off the job. 

d. Improvement in physical condition of em- 
ployes through advice of doctor and nurses. 

2. A substantial reduction in compensation prem- 
ium.* 

3. A reduction in the amount of compensation pay- 
ments, which under "Experience Rating" means 
a reduction in future insurance cost. 

4. The promotion of friendly relations with em- 
ployes through the services rendered by the 
hospital staff. 



Credits on premium are graduated according to equipment and surgical 
service, and the amounts vary in different states. Specific information on this 
point will be gladly furnished by our Underwriting Department. 



158 HEALTH SERVICE IN INDUSTRY 

It is quite certain that no such statements would 
be made unless the maintenance of a factory dis- 
pensary were of financial benefit to the insurance 
company and if to the insurance company, surely 
doubly so for the factory in which the service exists. 
The true effect of medical efforts can be determined 
accurately by the insurance companies who have the 
ability to make statistical studies of the effect of 
new work. The Metropolitan Life Insurance Com- 
pany in an open letter to members of its field force 
makes the following statement: 

"The reduction in the mortality from typhoid 
fever among Industrial policy-holders between 1911 
and 1919 was 69%. The acute infectious diseases 
of childhood showed a reduction of 46.7%. The 
death rate from tuberculosis of the lungs was re- 
duced 33.1%; from organic diseases of the heart, 
23.1%; from Bright's disease, 25.8%; from diseases 
relating to child-bearing, 6.5% and the external 
causes, including accidents, showed a reduction of 
7.9%." 

This reduction is ascribed largely to the work of 
the company's nursing service and "represented a 
saving of $2,605,625 in 1919 to the company. ' ' 

Finally it is interesting to note the action taken 
on the industrial medical department by the British 
Health of Munition Workers Committee in 1916.i 2 
At this time Great Britain was making her greatest 
effort in production. The committee closes its re- 
port with the following : 

"The committee have received evidence and re- 
ports from all parts of the country of the economic 
and industrial value of the proper organization of 



COST OF MEDICAL SUPERVISION 159 

a medical service within the factory, and they are 
convinced that both on grounds of health and of 
securing improved output this subject demands the 
immediate attention of employers, and that ade- 
quate schemes of treatment, especially of minor 
injuries, are an important means of preventing 
loss of time and efficiency among the workers. 
They recommend, therefore, that provision for or- 
ganized treatment should be made in every muni- 
tion factory." 



REFERENCES 

1. Selby, C. D. 

Studies of the Medical and Surgical Care of 
Industrial Workers. 

Public Health Bulletin No. 99. Washington, 
D. C. 

2. Mock, H. E. 

Industrial Medicine and Surgery. 

W. B. Saunders & Co., 1919. Philadelphia, Pa. 

3. Shipley, H. E. 

Health Service for Industries of Moderate Size. 
The Modern Hospital. April, 1920. Vol. XIV, 
No. 4. 

4. National Industrial Conference Board Health 
Service in Industry. Research Report No. 34. 

5. Geier, 0. P. 

Modern Medicine, December, 1920. 
Vol. II, No. 12. 

6. Selby, C. D. 

Scope of Physical Examination in Industry. 
Proceedings National Safety Council, 1919. 
Health Service Section. 

7. Dublin, J. J. and Lieboff, P. 
Occupation Hazards and Diagnostic Signs. 
Proceedings National Safety Council, 1920. 
Health Service Section. 



160 HEALTH SERVICE IN INDUSTRY 

8. Edsall, Wilbur & Drinker. 

The Occurrence, Course and Prevention of 

Chronic Manganese Poisoning. 

Journal Industrial Hygiene. Vol. I, No 4. 

9. Stevens, G. A. 
Cadmium Poisoning. 

Journal Industrial Hygiene. Vol. II, No. 4. 

10. Drinker, C. K. 

Economic Aspects of Industrial Medicine. 
Journal Industrial Hygiene. Vol. II, No. 2. 

11. Howe, G. L. 

Why a Factory Doctor's Salary Costs Less than 

Nothing. 

Factory, March 1, 1920. 

12. Newman, G. 
Sickness and Injury. 

Memorandum 10, British Health of Munition 
Workers Committee, 1916. 



INDEX 

PAGE 

Abdomen, Examination of 72 

Abrasions, First Aid Treatment of 39 

Treatment of 86 

Accident Record 137 

Accident Slip 138 

Accidents, After Care of 95 

Classification of 83 

Compensation for 10 

Course of Patient With 90, 91, and see Injuries 

First Aid Treatment of 39 

Moderately Severe 83 

Personnel for Handling 89 

Routine in Large Factories 31 

Severe 83 

Treatment of 89 

Trivial 83 

Acids, Burns from, First Aid Treatment of 40 

Air, 112, and see Ventilation 

Supply of, in Factories 114 

Alkalies, Burns from, First Aid Treatment of 40 

Asphyxiation, First Aid Treatment for 42 

Bleeding, First Aid Treatment of 39 

Treatment of 86 

Bronchitis (Mild) , Standard Treatment of 109 

Bruises, First Aid Treatment of 40 

Burns, Treatment of 86 

Burns, from Acids, First Aid Treatment of 40 

From Alkalies, First Aid Treatment of 40 

Carbon Dioxide, Amount allowed in Air in Factories 114 

Cardiac, and see Heart. 

Cardiac Substandard Men 76 

Centralized Dispensary Service for Small Factory 21 

Chest, Examination of 71 

Chills, First Aid Treatment for 41 

161 



162 INDEX 

PAGE 

Closets, Care of 121, 122 

Number Required 123 

Type Recommended 122 

Compensation for Accidents 10 

Constipation, Standard Treatment of 110 

Cooperation of Health Department with Others 103 

Coryza, Standard Treatment of 109 

Cost, of Health Supervision 150 

Of Medical Supervision 147 

Of Sanitation 150 

Cramps, First Aid Treatment of 41 

Crushing Injuries, Treatment of 88 

Cuspidors 125 

Cuts, First Aid Treatment of 39 

Diagnosis, Accurate, Value of 102 

Dislocation, First Aid Treatment of 40 

Dispensaries 37, 46 

Equipment 43, 46, 49 

Units 48 

Dispensary Nurse 63 

Duties of 63 

Dispensary Service, Centralized, for Small Factory 21 

Dizziness, First Aid Treatment of 41 

Doctors, Salaries of 148 

Full Time 149 

Part Time 148 

Draught 113 

Drinking Fountain, Type of 120 

Drinking Water 120 

Dust 118 

Dangerous Types of 119 

Effects of Inhaling: 119 

Ears, Examination of 70 

Economics of Industrial Hygiene 147 

Electric Burns, First Aid Treatment in 40 

Electric Lights, to be Kept Clean 125 

To be Replaced 125 

Electric Shock, First Aid Treatment for 42 

Employes, Health Supervision of 4 

Adjuncts to 4 

Management of Health of in Large Factories 28 

Employment Department, Functions of 8 



INDEX 163 

PAGE 

Enteritis (Mild) , Standard Treatment of 110 

Examination, Physical 69, 128 

Executive Force, Examination of 127 

Extremities, Examination of 72 

Eyes, Burns, First Aid Treatment of 40 

Examination of 70 

Foreign Bodies in, First Aid Treatment of 40 

Injuries of, First Aid Treatment of 40 

Treatment of 87 

Factory, Carbon Dioxide in Air of 114 

Factory Dispensaries 37, 46 

Equipment of 46, 49 

Units of 48 

Factory Organization, Basis of 2 

Factory, Hazards in 101 

Sickness in, See Sickness in Factory. 

Statistics of 145 

Fainting, First Aid Treatment of 41 

Fibrosis of the Lungs 119 

Fingers, Fractures of, Treatment 88 

Fire Burns, First Aid Treatment of 40 

First Aid Jar, N. A. S. 38 

First Aid Station 37 

First Aid Treatment 39 

Flies, Trapping of 126 

Foreign Bodies in Eye, First Aid Treatment of 40 

Foreman and Physician, Cooperation between 60, 103 

Fractures, First Aid Treatment of 41 

Treatment of 86 

Fractures of Fingers, Treatment of 88 

Frost Bite, First Aid Treatment of 41 

Gas, Asphyxiation, First Aid Treatment of 42 

Gastritis (Mild) , Standard Treatment of 109 

Gastro-enteritis (Mild), Standard Treatment of 110 

Hazards in Factories 101 

Headache, First Aid Treatment of 41 

Standard Treatment of 110 

Health Bulletins 100, 101 

Health Bureau for Small Factories 22 

Health Department 5 

Functions of 127 



164 INDEX 

PAGE 

Health Department — 

Relation to Other Departments 8 

Organization Chart of 24 

Specific Problems of 127 

Health Section in Large Factories, Equipment of 26 

Function of 26, 27 

Health Supervision 4 

Adjuncts to 4 

Benefits of 152 

To Employers 157 

To Workers 155 

Cost of 150 

Heart, and see Cardiac. 

Examination of 71 

Questionnaire 139 

Heat, in Factories 118 

Heat Prostration, First Aid Treatment of 41 

Hemorrhage, First Aid Treatment of 39 

Treatment of ' 86 

Hernia, Examination for 72 

In Substandard Men 79 

Housing 12 

Humidity, in Factories 118 

Illumination, 114, and see Lighting. 

Measurement of 115 

Indigestion, Standard Treatment of 109 

Industrial Hygiene, Economics of 147 

Industrial Medicine 55 

Industrial Nurse 54, 61, 63 

Rules for 62 

Salary of 149 

Industrial Physician 54 

And Foreman 103 

And General Practitioner 103 

And Specialist 104 

Cooperation with Management 60 

Part-time 55 

Results and 58 

Salaries of 148, 149 

Time and 59 

Industry 1 

And Factories 1 

And Organization 1 

Infection, Prevention of 84 



INDEX 165 

PAGE 

Injuries, and see Accidents. 

And Safety Engineering Department 92 

And Visiting Nurse's Service 93 

Course of 92, 93 

Joints, Examination of 73 

Kidneys, see Nephritic. 

Lacerations, Treatment of 88 

Large Factories, Accident Routine in 31 

Health Section in, Equipment of 26 

Function of 26 

Management of Health of Employe in 27, 28 

Organization of Medical Department in 25 

Sanitation Service in 33 

Administration of 33 

Function of 26 

Sanitation Service in 26 

Sickness Routine in 31 

Standards in 30 

Visiting Nurse Section in 35 

Functions of 26 

Lead Questionnaire 142 

Lighting, and see Illumination. 

Artificial, Fundamental Items of 116 

Types of 117 

Direct 117 

Indirect 117 

Semidirect 117 

Standards of 116 

Lockers 124 

Care of 125 

Locker Rooms, Care of 124 

Equipment of 124 

Lung Questionnaire 141 

Lungs, and see Pulmonary. 

Examination of 71 

Fibrosis of 119 

Medical Department 5 

Relation to Other Departments 8 

Medical Supervision, Cost of 147 

Mouth, Examination of 70 



166 INDEX 

PAGE 

N- A. S. O. First Aid Jar 36, 38 

Nausea, First Aid Treatment in 41 

Neck, Examination of 71 

Nephritic Substandard Men 78 

Nose Bleed, First Aid Treatment of 39 

Nose, Examination of 70 

Nurse, Dispensary 63 

Nurse, Industrial 54, 61, 63 

Rules for 62 

Salary of 149 

Nurse, Visiting 26, 35, 66 

Organization Chart of Health Department 24 

Paper and Refuse, Collection of 126 

Part-time Physician for Small Factory 17, 148 

Patient with Accident, Course of 90, 91 

Pharyngitis, Standard Treatment of 109 

Photometer 115 

Physical Examination 69, 128 

Physician, Industrial, see Industrial Physician. 

Poisoning, Internal, First Aid Treatment of 41 

Prevention of Sickness 98 

Production 2 

Pulmonary, and see Lungs. 

Substandard Men 78 

Punctured Wounds, First Aid Treatment of 39 

Of Foot, Treatment 88 

Questionnaire, Heart 139 

Lead 142 

Lung 141 

Rats, Trapping of 126 

Receptacle for Soiled Dressings 52 

Record System 135 

Important Points in 135 

Sample 137 

Recreation 12 

References 159 

Refuse and Paper, Collection of 126 

Restaurant Service 11 

Safety Engineering Department 10 

Relation of Injuries to 92 



INDEX 167 

PAGE 

Sanitary Appliances Ill 

Sanitary Force of Factory, Duties of 125 

Sanitary Foreman Ill 

Sanitary Inspector, Duties of 112 

Sanitary Section in Large Factory 33 

Administration of 33 

Functions of 26 

Sanitation Ill 

Conditions Requiring Control Ill 

Cost of 150 

Report 34 

Service Division, of Factories, Functions of 4, 5 

Layout of 6 

Sewage, Disposal of 121 

Shock Following Injuries, First Aid Treatment of 42 

Sickness in Factory 97 

Curative Work in 105 

Effects of 97 

Prevalence of 105 

Prevention of 98 

Sickness Record 137 

Sickness Routine at Large Factory 31 

Sickness Slip in Minor Ailments 108 

Skin, Examination of 72 

Slip, Accident 138 

Slivers in Skin, First Aid Treatment of 40 

Small Factory, Centralized Dispensary Service for 21 

Health Bureau for 22 

Medical Equipment of 18 

Medical Needs of 15, 17 

Part Time Physician for 17 

Smoke, Asphyxiation from, First Aid Treatment for 42 

Splinters in Skin, First Aid Treatment of 40 

Soiled Dressings, Receptacle for 52 

Sprains, First Aid Treatment of 40 

Treatment of 86 

Standard Treatments 109 

Strains, Treatment of 86 

Sub-Dispensary 37, 42 

Equipment of 43, 46 

Substandard Workmen, Cardiac Cases 76 

Classification of 75 

General Cases 81 

Hernial Cases 79 



168 INDEX 

PAGE 

Substandard Workmen — 

In Large Factories 30 

Nephritic Cases 78 

Physically 75 

Pulmonary Cases 78 

Re-examination of 81 

Special Cases 81 

Syphilitic Cases 80 

Sunburn, First Aid Treatment of 40 

Supervision of Health of Employes 4 

Syphilis, in Substandard Men 80 

Tonsilitis, Standard Treatment of 109 

Trachitis, Standard Treatment of 109 

Tuberculosis, Latent 78 

Unconsciousness, from Asphyxiation, First Aid Treat- 
ment of 42 

From Fainting, First Aid Treatment of 41 

From Gas, First Aid Treatment of 42 

From Smoke, First Aid Treatment of 42 

From Water, First Aid Treatment of 42 

Units of Factory Dispensaries 48 

Urinals 123 

Number Required 123 

Ventilation 112 

Duty of Physician in 114 

Methods of 113 

Visiting Nurse, Work of 66 

Visiting Nurse Section in Large Factories 35 

Function of 26 

Visiting Nurse Service 10 

And Injuries 93 

Washing Fixtures 124 

Water, Asphyxiation from, First Aid Treatment of 42 

Weekly Sanitation Report. 34 

Windows to Be Kept Clean 125 

Wounds, First Aid Treatment of 39 

Treatment of 85, 86, 88 

Wounds, Punctured of foot, Treatment of 88 

X-Ray Examination, Value of in Diagnosis 79, 87, 129 



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